RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1.NAME OF THE CANDIDATE

AND ADDRESS

MS. PRITI RANI BHARDWAJNOOR COLLEGE OF NURSING,

BHOOPSANDRA MAIN ROAD,

BANGALORE –560 094.

2. NAME OF THE INSTITUTION

NOOR COLLEGE OF NURSING.

NO.5, NOOR BUILDING, RMV 2ND

STAGE, BHOOPSANDRA MAIN

ROAD, BANGALORE – 560 094.

3.COURSE OF STUDY AND

SUBJECT

M.Sc. NURSING I YEAR

PAEDIATRIC NURSING.

4.DATE OF ADMISSION TO

COURSE01-06-2011

5. TITLE OF THE TOPIC

A STUDY TO ASSESS THE

EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME

REGARDING KNOWLEDGE ON

NEONATAL JAUNDICE AMONG

STAFF NURSES IN SELECTED

HOSPITAL BANGALORE.

1

6. BRIEF RESUME OF THE INTENDED WORK

6.0 INTRODUCTION

“Having a baby’s sweet face so close to your own, for so long a time as

it takes to nurse, is a great tonic for a sad soul”

-------ERICA JAMES

With the birth of every child, man may calculate that God is still hopeful about

the world He Created. But healthy survival of the children is threatened at every moment.

Child health problems are shocking and alarming throughout the world, especially in the

developing countries. Expert and empathetic approach is essential to minimize these

problems and to reduce the inexcusable causes of childhood morbidity mortality and

disability.1

New born are considered to be tiny and powerless and more of all treasure to the

nation, completely dependent on others for their adaptation in the external environment

within one minute of birth the normal newborn adapts from dependant fetal existence to

an independent one capable of oxygenation and carry on physiological processes.

Understanding and appreciating this transition are vital to the assessment and care of

newborn babies.2

During this process of the physiological process or adaptation for its survival of

the infants life or neonates have to face many life threatening problems such as asphyxia,

hypothermia, hyperthermia, infections and neonatal jaundice etc. So the assessment and

care of newborn is very essential.3

Among these problems neonatal jaundice is the commonest problem among

infants in neonatal period. The word jaundice is derived from the French word Jaune

which means Yellow. Clinical jaundice manifests as yellowness of the skin of the face

when the serum bilirubin level exceeds 5mg/dl. As the degree of jaundice increases, there

2

is a cephalocaudal progression of the yellowness of the skin.when the trunk of the baby is

distinctly yellow stained, the serum bilirubin levels is likely to range between 10 to

15mg/dl. The yellow staining of the palms and soles indicates that serum bilirubin level

has exceeded 15mg/dl.4

Neonatal jaundice affects 60%of full term infants and 80% of preterm infants,

bilirubin level greater than 5mg/dl in the first week of life and about 6% of term babies

will have bilirubin levels exceeding 15mg/dl. Neonatal jaundice is a yellowing of the skin

and other tissues of a newborn infant with a bilirubin level of more than 5mg/dl.5

Infants jaundice is restricted to the face and part of the trunk and above the

umbilicus all have the bilirubin level less than 12mg/dl. Infants whose palm and sole are

yellow have serum bilirubin level over 15mg/dl.6

Bilirubin is a yellowish red pigment formed during breakdown of red blood cells.

It is normally present in the blood in small quantities when there is excessive red blood

cell breakdown the bilirubin level in the blood goes up and it also gets deposited in

tissues impacting a yellow colour to the skin.7

In normal benign jaundice tends to develop because of two factors, the breakdown

of fetal hemoglobin as it is replaced with adult hemoglobin and the relatively immature

hepatic metabolic pathways which are unable to conjugate and so excrete bilirubin as

quickly as adult. This causes an accumulation of bilirubin in the blood leading to the

symptoms of jaundice.8

Focuses on the importance of monitoring and identifying those early discharged

infants who are at risk for developing complications of jaundice, by utilizing standing

orders in monitoring babies within 24hours of discharged, bilirubin level can be assessed

in the home setting, required interventions can be implemented and unplanned emergency

room visits and hospital readmissions can be saved.9

Caring for these newborns those are acutely ill is paramount important and also

challenging today. It requires a high-tech nursing care, to implement this, the nurses

caring for these children need to be knowledgeable and should possess adequate skill.

6.1 NEED FOR THE STUDY

3

More than 40% of the population of our country falls in the age spectrum covered

by pediatrics. Infants (0-1 years) constitute 2.82% of the total population in India. Infants

are a sensitive group that requires care from efficient and competent persons to meet their

special needs. They demands special concern for survival. It is the responsibility of the

nurse to fulfill the demands of the newborn.10

Neonatal jaundice is a common problem affecting over half of all full term and

most of the preterm infants. Jaundice is noticed during the first week of life after birth.

Healthcare providers need to be familiar with the diagnosis and management of jaundice

to prevent brain, vision and hearing damage. Treatment of choice for jaundice remains

close observation and frequent feeding followed by phototherapy and finally exchange

transfusion for sense or refractory.9

The WHO reveals the source of incidence of hypebilirubinemia is 50 to 60,000

neonates reported 2% has total serum bilirubin levels over 20mg/dl, the total serum

bilirubin level in normal range is0.3 to 1mg/dl.0.15%had levels over 25 mg/dl and 0.01%

has over 30mg/dl. Thus we can expect 50,000 in chat 6000 and 400 new borns with

bilirubin levels of greater than 20mg/dl and 30mg/dl. Hyperbilirubinemia is one of the

most common problems encountered in newborns. Historically, management guidelines

were derived from studies on bilirubin toxicity in infants with hemolytic disease. More

recent recommendations support the use of less intensive therapy in healthy newborns

with jaundice.11

Each year in India over one million new born dies before they complete their first

month of life, accounting for 30% of the world’s neonatal death India’s current neonatal

mortality rate of 40 per thousand live births represents 1.2 million children who die each

year. Neonatal mortality is higher in rural areas at 50 per thousand live births. The

neonatal mortality rate also varies considerably among Indian states. Orissa and Madhya

Pradesh have the highest neonatal mortality rates of 61(rural 63, urban 42) and 59 (rural

63, urban 40) per 1000 live births respectively. In Uttar Pradesh the rate is 53/1000(rural

56, urban 39) and 31/1000(rural 33, urban 21) in west Bengal. Kerala has the lowest

neonatal mortality of 10/1000(rural 10, urban 9), followed by Punjab 29/1000(rural 32,

4

urban19).The Government of India is committed to reduce the neonatal mortality rate to

approximately 20/1000 live births by 2015.12

Two-thirds of infant deaths in India occur in the first month of life.

Approximately three-quarters of Indian neonatal deaths occur within one week of birth

while 90% occur within the first 2 weeks of life. A major challenge in Indian rural areas

is that most of the births take place at home, assisted by untrained personnel. As well as

the risks associated with the use of traditional birth attendants, the environment into

which a child is born also influences survival. It is, therefore important to know about

risk factors and prevention of neonatal jaundice.13

In UK incidence of severe hyperbilirubinemia was 7.1/ 100000 live births. Only

20 cases presented in hospital; 88 were admitted with severe jaundice. Co- morbidity

included hemolysis, dehydration, infection and bruising. 14 infants showed evidence of

bilirubin encephalopathy ,of which 3 died. The UK incidence of bilirubin encephalopathy

was 0.9/100000 live births.14

In United States, 4.3% of 47,801 infants had total serum bilirubin (TSB) levels in

a range in which phototherapy was recommended by the 2005 American Academy of

Pediatrics(AAP) guidelines, and 2.9% had values in a range in which the 2005 AAP

guidelines suggest considering phototherapy.15

A study undertaken to evaluate the etiological factors responsible for neonatal

jaundice in Shimla, India among 164 neonates. The findings shows that 105(64%)

developed clinical jaundice. 68( 64.5%) were boys and 37(35.2%) were girls. Serum

hyperbilirubinemia was found in 38 cases(23.1%). In 12(11.4%), no cause could de

determined for the jaundice. Physiological jaundice was determined in 67 (63.7%) cases

could be determined. Sepsis associated with jaundice was found in 11 (10.5%) cases.16

The study on Neonatal surgical jaundice revisited shows nearly 25 – 50 % of all

new borns and a much higher percentage of premature babies develop

hyperbilirubinemia. It also consider a possibility of extra hepatic biliary atresia early.

During management of a case of direct hyperbilirubinemia as surgical intervention results

in a better out come.17

5

A study conducted on Exchange transfusion for neonatal jaundice in Nigeria to

determine the indication for exchange blood transfusion(EBT) in neonatal jaundice and

what proportion of EBT was possibly avoidable among 1686 babies admitted in the

neonatal unit. The study findings shows that90 (5.3%) had BBT. Fourteen (15.6%) were

inborn while 76(84.4%) were out born babies. Fifty six (62.2%) babies were primarily

for neonatal jaundice while 34(37.8%) developed neonatal jaundice (NNJ) during

admission. Thirty six (40%) of the babies had phototherapy for more than 24 hours prior

to EBT either because they were of very low birth weight or NNJ was detected very early

therapy was commenced. Sixty-eight (75.6%) babies had single EBT while the remaining

22 (24.4%) had two sessions of EBT. The study concluded that EBT rate in the center

was high. With more effective phototherapy, EBT could be avoided in most of the babies,

who initially had phtotherapy for more than 24 hours before EBT and repeated EBT

sessions.18

The study on Management of neonatal hyperbilirubinemiashows among the total

of 114 Newborns in Karnataka. The study revealed that 33.3% (38/114) underwent

exchange transfusion by push-pull and 66.7% (76/114) iso volumetric technique. When

these two techniques are compared, 59.2% in iso volumetric and 57.9% in push-pull

group had more than 40% reduction in bilirubin level. In neonatal hyperbilirubinemia

exchange transfusion reduces the bilirubin level rapidly by about 40%.The iso volumetric

and push pull techniques are comparable in efficiency.19

The study on Jaundice- the newborn babies shows the yellow discoloration of the

skin and sclera that results from raised levels of bilirubin in the blood. Neonates it

appears when serum bilirubin concentration reach 85- 120 mol/l with cephalo caudal

progression as levels increase. Asian and Native American babies usually have higher

bilirubin levels than Caucasian infants whereas babies of African origins have lower

levels. Preterm babies are more likely to develop jaundice. Pathological jaundice in

newborn appears within 24 hours of birth. Rh D incompatibility can occur when a women

with Rh negative blood type is pregnant with a fetus with Rh positive blood type. This is

commonest among Caucasians about 15%, 8% in Africans and 1% in Asian population.20

6

There are so many complications related to the neonatal jaundice such as

mortality, hearing loss, incidence of kernicterus, adverse events caused by

hospitalizations as parent infant bonding, failure of treatment, length of hospital stay and

need for transfusion. Kernicterus refers to the yellow staining of the deep nuclei of the

brain, which includes symptoms such as athetoid cerebral palsy, hearing loss, failure of

upward gaze and dental enamel dysplasia. By educating the staff nurses about neonatal

jaundice and its complications they can do interventions in clinical area to prevent

complications.21

For successful management, the staff nurses should have adequate knowledge on

early detection, level of serum bilirubin and interventions. The overall aims of the study

is to provide information about neonatal jaundice to prevent complications of neonatal

jaundice by staff nurses. Considering the above study findings the researcher understood

that the staff nurses need to be specially trained.

The investigator while working in neonatal intensive care unit (NICU) had

cared for the babies with jaundice. Most of the babies treated with phototherapy and

some babies with exchange transfusion to reduce the bilirubin level. From there the

investigator found that neonatal jaundice is very common and become very serious to

cause death in neonates from inadequate interventions. So the investigator felt the need

for the study.

6.2 Review of Literature

It refers to an integral component of any study or research projects. It enhances

the depth of the knowledge and inspires a clean insight into course of the problem.

Literature review throws light on the studies and their reports about the problem under

the studies.

The studies related to the topic are organized and presented under the following

headings.

7

A. Study related to incidence and prevalence of neonatal jaundice.

B. Studies related to risk factors of neonatal jaundice.

C. Studies related to management of neonatal jaundice.

D. Studies related to complications of neonatal jaundice.

E. Studies related to effectiveness structured teaching programme.

A. Study related to incidence and prevalence of neonatal jaundice.

A cross-sectional study was conducted to identify and incidence and prevelance

related to st “Redcell pyruvate deficiency in neonatal jaundice in India” among 218

neonates. The study shows that 7 of the 218 cases of neonates were PK( pyruvatef

kinase) deficient with 30-40%

reduction in PK activity. The study concluded that the prevalence of PK deficiency in

Indian neonatal jaundice case is 3.2%, which is relatively high. This emphasis the need

for screening neonatal hyperbilirubinemia cases in India for PK deficiency prevalence-

estimated people managing neonatal jaundice incidence-annual diagnosis.22

A study was conducted on incidence, course and prediction of hyperbilirubinemia

among 23 term newborns and 37 in the near term groups. The study was conducted with

the aim to compare the serum bilirubin levels among the groups. The study found that on

the first 4 days values did not significantly differ between the groups, whereas on the 5 th

and 7th days values were significantly higher in the near term groups. The study

recommended that regular monitoring of the serum bilirubin will help in early diagnosis

and treatment.23

A prospective study among 1238 full-term Chinese newborn infants was

conducted to determine the incidence of neonatal jaundice and associated factors. A

significantly more severe degree of hyperbilirubinaemia was present in infants whose

ABO blood group was incompatible with that of their mothers and those who were

8

deficient in the enzyme glucose-6-phosphate dehydrogenase (G6PD). Among the

remainder, clinical jaundice was present in 87% and 23.9% had a peak serum bilirubin

(SB) concentration greater than 204 mumo l/l. Factors that were found to have an

association with a higher peak SB concentration included: male infants; elder siblings

who had a history of neonatal jaundice; and breast-fed infants with or without

supplementation with formula feed. Factors that were found to have no significant

association with the peak SB concentration were: gestational age; birth weight; the mode

of delivery of the infants; maternal consumption of Chinese herbs and syntocinon

induction or augmentation of labour.24

A population-based prospective study was conducted to estimate the incidence of

neonatal jaundice and hyperbilirubinemia in a poor urban community among 1690 in

Karachi, Pakistan ao. Clinical assessments of jaundice were assigned by a physician and

recorded using an adapted Kramer scale. Blood for plasma bilirubin was obtained if

parents consented. The study findings reveled that Bilirubin was measured in 125 of 466

(27%) jaundiced newborns. Overall detected rate of hyperbilirubinemia (bilirubin >5

mg/dl) among 1690 newborns was 39.7/1000 live births (95% CI 29.3-47.6). Rate of

plasma bilirubin levels in the range of 15-20 mg/dl was 13/1000 live births (95% CI 7.6-

18.4); levels >20 mg/dl were observed in 3.5/1000 live births (95% CI 0.4-5.5). The

proportion of newborns with bilirubin > or =15 mg/dl was significantly higher among

those assigned a Kramer score of 4-5 compared to those receiving a score of 1-3 (P-value

0.00004). The study concluded that untreated severe neonatal jaundice, causing potential

neurological squeal, exists in developing countries such as Pakistan. WHO guidelines are

needed for screening and appropriate management of neonatal jaundice in developing

countries.25

B. Studies related to risk factors of neonatal jaundice.

A study was conducted on 50 pregnant mothers and their 52 newborns in western

Uttar Pradesh for Several maternal and fetal factors which are responsible for neonatal

jaundice, which is a common observation in large number of newborns. In addition

newborns with congenital or chromosomal abnormalities were excluded. Serum

concentrations of bilirubin of all neonates were measured on days 1, 3 and 5. It was found

9

to be lower on day 1, with a peak at day 3. The area under serum bilirubin level-time

curve for each neonate was also calculated. Fetal sex and birth weight were not found to

significantly affect the neonatal hyperbilirubinemia. Newborn of bipara mothers were

found to have significantly lower (P < 0.05) serum bilirubin level on day 1 as compared

to primipara mothers only but higher (P < 0.05) on day 3 as compared to either primi or

multipara mothers. Yet, of serum bilirubin curve was significantly higher (P < 0.05) in

newborns of bipara mothers than others. Significantly (P < 0.05) higher serum bilirubin

on day 1 was also observed in preterm neonates than full term ones. However, maternal

haemoglobin and mode of delivery were not shown to affect the neonatal bilirubin levels

in these newborns.26

A prospective study was conducted to identify the role of genetic factors in

occurance of neonatal jaundice. Totally 109 umblical cord blood samples were collected

for the screening of G-6-PD activity. According to G-6-PD activity and G71R or A388 G

genotype, the genotypes were allocated into different groups. The study concluded that

UGTIAI G71IR gene mutation combined with G-6-PD deficiency or A388G gene

mutation combined with G-6-PD deficiency play a co-ordinate role in the development of

neonatal hyperbilirubinemia.28

A study was conducted on epidemiology of clinical hyperbilirubinemia in United

Arab Emirates. Total 2300 live births were prospectively studied. In this 85(3.7%) were

developed hyperbilirubinemia of these, 22 were premature, 22 had ABO hemolytic

disease of the newborn, 8 had G6PD deficiency, 7 had breast milk jaundice, 5 were born

to mothers with diabetes mellitus and 1 had Rh incompatibility. No specific factor was

identified in 20(24%).29

A study was conducted to determine etiological spectrum as well as clinical

profile of chronic hepatobiliary disorders in children 45 children with chronic

hepatobiliary among 105 children with liver diseases referred to the childs clinic in Bidar,

Karnataka. All underwent detailed history and clinical examination. Clinical and

laboratory features as well as causes of chronic hepato biliary disorders were studied. The

study reveals that the common causes were biliary atresia in 11 (25%) patients, neonatal

hepatitis and Wilson's disease in 6 (13%) patients each, glycogen storage disorder (GSD)

and idiopathic hepatitis in 5 patients (11%) each, Hepatitis B in 2 (5%), Hepatitis C in 1

10

(2%), Hepatitis B and C in 1 (2%), Caroli's disease in 2 (5%), autoimmune hepatitis in 2

(5%); sclerosing cholangitis, viral hemophagocytosis and thalassemia major in 1 (2%)

patient each. Common clinical presentations were jaundice in 32 (71%), dark urine in 19

(42%), fever in 13 (29%), failure to thrive in 7 (16%), splenomegaly in 21 (47%) and

hepatomegaly in 32 (71%). Also children with neonatal cholestasis presented in 1s' year

of life, those with idiopathic liver disease and GSD presented within 1st 5 years of life

and those with Wilson's disease. Autoimmune hepatitis, Caroli's disease presented

between 5-10 years of age and viral hepatitis was seen in 2nd decade of life (p < 0.001).

The study concluded that the study has commonest cause of chronic hepatobiliary

disorders in children is neonatal hepatitis. Metabolic liver disease usually presents in 1st

5 years of life whereas chronic viral hepatitis has a presentation in adolescence.30

C. Studies related to management for neonatal jaundice.

A study was conducted on effect of light on total micro-bilirubin values in vitro in

Taipei. 616 capillary blood samples were collected from jaundiced newborn infant. These

samples were randomly divided into three groups. One group contained 133 samples and

would receive phototherapy with blue light. Another group contained 202 samples would

receive room light or white light. The final groups contained 215 samples and wer left in

a dark room. The total bilirubin levels were checked at 0,2,4,6,24,48 hrs. there was a

significant decrease in bilirubin in the first group exposed to phototherapy after 2 hours,

but no change occurred in 2nd &3rd group. After 6 hrs there was significant change

bilirubin level in the white light group but not in the 3rd group. It took 48hrs to record a

change in the dark room group’s bilirubin level.31

A study conducted as Phototherapy of the newborn a predictive model for the

outcome. The work aims at finding a predictive model for the decrement of blood

bilirubin followed conventional phototherapy. It is possible to predict the total blood

bilirubin of the patient under phototherapy by knowing its birth weight, bilirubin level at

the beginning of treatment, duration of exposition, and irradiance. Besides, it is possible

to infer the time necessary for a given decrement of bilirubin, under approximately

constant irradiance.32

11

A study conducted on Treatment of physiological and pathological neonatal

jaundice. If hyperbilirubinemia necessitates, treatment involves phototherapy and /or

exchange transfusion of donor blood. In cases of pathological jaundice the underlying

cause must also be treated. Parental involvement is important to minimize the trauma of

having a sick baby and its effect on bonding.33

A comparative study was conducted to assess the effectiveness of various

phototherapy system in lowering serum bilirubin levels among 140 preterm infants.

Efficacy was assessed by comparing highest serum bilirubin levels, duration of treatment,

and numbers of infants requiring exchange transfusion. The results confirm that that

fibroptic phototherapy, both wallaby and Biliblanket, had the same effectiveness of

conventional phototherapy. The data suggested that combined phototherapy should be the

method of choice in treating hyperbilirubinemia in very preterm infants.34

D. Studies related complications of neonatal jaundice.

A study on sensorineural hearing loss in infants with neonatal jaundice in Lagos:

a community based study among 234 infants . The study shows that Fourteen (6%) of the

234 infants with neonatal jaundice (NNJ) had sensorineural hearing loss (SNHL). The

study concluded that SNHL is prevalent among infants with NNJ.35

A prospective study conducted on Magnetic resonance imaging (MRI) in

Kernicterus in Karache, Karnataka. The study that shows kernicterus is a disease entity

with very high rate of mortality in neonates. The children who survive are left with

neurological deficits such as choreoathetosis, sensorineural deafness and mental

retardation. Magnetic imaging of the brain in this condition has specific findings which

aid in the accurate diagnosis of the condition, along with clinical and biochemical

criteria. Reports have shown involvement of the globus pallidus, putamen and less

commonly thalamus.36

A study was conducted to determine the complication of post-phototherapy

bilirubin rebound in neonates. Subjects included 232 inborn neonates needing

phototherapy for hyperbilirubinemia. Standard guidelines were used to start and stop

phototherapy. Rebound bilirubin was measured 24+/-6 h after stopping phototherapy.

12

Significant bilirubin rebound (SBR) was defined as post-phototherapy bilirubin level

needing reinstitution of phototherapy. Among 245 neonates with hyperbilirubinemia,

post-phototherapy bilirubin estimation was done in 232 neonates. A total of 17 (7.3%)

neonates developed SBR. In neonates with SBR, bilirubin increased by 2.3 mg/dL (95%

CI 1.6-3.0) after stopping phototherapy. Risk factors for SBR included birth at >35 weeks

of gestation (RR 4.3, 95% CI 1.5-12.0), birthweight<2000 g (RR 3.2, 95% CI 1.0-10.3)

and onset of jaundice at >60 h of age (RR 3.3, 95% CI 1.2-9.0). Post-phototherapy

discharge and follow-up planning is recommended.37

A retrospective cohort study was conducted to assess the risk of skin cancer in

persons treated with neonatal phototherapy for jaundice in Grampian Region, Scotland,

UK Main outcome measures were Incidence ratios, standardized for age, sex, calendar

period and socio-economic position. The study revealed that After excluding neonatal

deaths (n=435), the cohort comprised 77,518 persons. 5868 Received neonatal

phototherapy, providing 138,000 person-years at risk (median follow-up, 24 years). Two

cases of melanoma occurred in persons exposed to neonatal phototherapy versus 16 cases

in unexposed persons, yielding a standardized incidence ratio of 1.40 (95% CI, 0.17 to

5.04; p=0.834). No cases of squamous cell or basal cell carcinoma of skin were observed

in exposed persons. Author concluded by saying although there is no statistically

significant evidence of an excess risk of skin cancer following neonatal phototherapy,

limited statistical power and follow-up duration mean it is not possible categorically to

rule out an effect. However, taken in conjunction with the results of the only other study

to investigate risk of melanoma following neonatal phototherapy, evidence available so

far does not suggest a major cause for concern.38

E. Studies related to structured teaching programme

A study was conducted on Visual assessment of jaundice in term and late preterm

infants Nurses assessment of jaundice extent was only moderately correlated with

13

bilirubin concentration. The correlation was particularly weak among infants <38weeks’

gestational age. Compared with infants 38 weeks gestation but complete absence of

jaundice had high sensitivity (95%) and excellent negative predictive value (99%). The

study concluded that clinicians should not use extent of cephalocaudal jaundice

progression to estimate bilirubin levels during the birth hospitalization, expecially in late

pretem infants. The complete absence of jaundice can be used to predict with the very

high accuracy which infants not develop significant hyperbilirubinemia.39

A study on Better care and better teaching. New model of postpartum care for

early discharge programmes. Newborn infants and their mothers are seen by a family

physicians, a family medicine resident and a nurse within 48 hrs of discharge. An

assessment protocol development by the interdisciplinary group promotes standardized

mother and child care and a structural learning experience for trainees. The study

concluded that assessement occurs in a teaching mileu, a comprehensive learning

experience can be combined with defined objectives that emphasize and encourage

newborn and maternal assessement for ambulatory patients.40

6.3 STATEMENT OF PROBLEM

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME REGARDING KNOWLEDGE ON NEONATAL

JAUNDICE AMONG STAFF NURSES IN SELECTED HOSPITAL

BANGALORE .

6.4 OBJECTIVES OF THE STUDY

1. To assess the knowledge on neonatal jaundice among staff nurses.

2. To assess the effectiveness of structured teaching programme on Knowledge

regarding neonatal jaundice among staff nurses.

14

3. To determine the association between pre-test knowledge score and selected

demographic variables.

6.5 OPERATIONAL DEFINITION

1. Assess: In the present study assess refers to the organized systematic and

continuous process gathering information of knowledge on neonatal jaundice

among staff nurses.

2. Effectiveness: In this study effectiveness means “Improving the knowledge

regarding neonatal jaundice among staff nurses by structured teaching programme

which may result differences between pre and post test knowledge score”.

3. Structured teaching programme: In the present study it refers to systematically

planned teaching programme designed to provide information regarding neonatal

jaundice among mothers of under five children.

4. Knowledge: It refers to the ability of the staff nurses in giving correct responses

to the questions asked as measured by structured knowledge questionnaire

5. Neonatal jaundice: Yellowish discolouration of the whites of the eyes and skin

caused by the deposition of bile salts in these tissues, occurring as sign of

disorders that interfere with normal metabolism or transport of bile.

6. Staff nurse: In this present study staff nurses refers to those who is providing

professional nursing care in Mediscope hospital with qualifications of General

nursing and Midwifery or Bachelor of Science in nursing with 3 years experience.

6.6 HYPOTHESIS

There will be a significant difference in the level of knowledge among staff

nurses regarding neonatal jaundice before and after administration of structured

teaching programme.

15

6.7 ASSUMPTION

1. Staff nurses may have inadequate knowledge regarding neonatal jaundice.

2. Structured teaching programme can significantly increases their knowledge level

regarding neonatal jaundice among staff nurses.

6.8 DELIMITATION

1. The study is limited to only staff nurses in selected paediatric ward.

2. The knowledge of staff nurses will be assessed only through a structured

knowledge questionnaire.

3. The study is delimited only to a small group not to a whole population.

7 MATERIAL AND METHODS

7.1 SOURCE OF DATA

The data will be collected from the staff nurses in selected paediatric ward.

7.2. RESEAGCH APPROACH:

An evaluative research approach

7.3 RESEARCH DESIGN:

One group pre-test and post-test experimental design.

7.5 SETTING:

The study will be conduct in Mediscope Hospital, Bangalore.

7.6 POPULATION:

The population of present study comprises of staff nurses in Working selected

hospital

7.7 SAMPLE:

Staff nurses who are working in Mediscope Hospital, Bangalore.

7.8 SAMPLE SIZE:

The total study sample consists of 30 staff nurses.

7.9 SAMPLE TECHNIQUE:

Purposive sampling technique.

16

7.10 INCLUSION AND EXCLUSION CRITERIA

A) Inclusion criteria:

1 .Staff nurses who have more than 3 years of experience.

2. Staff nurses who are willing to participate.

3. Staff nurses who are available during the data collection

B) Exclusion criteria

1. Staff nurses who had attended special training in neonatal jaundice.

2. Staff nurses who are not available during data collection.

8. DESCRIPTION OF VARIABLES

INDEPENDENT VARIABLE: Structured Teaching Programme.

DEPENDENT VARIABLE: Knowledge of staff nurses regarding neonatal

jaundice.

9 METHODS OF DATACOLLECTION

Prior to data collection, permission will be obtained from the concerned

authority. After accepting the permission the following steps will be taken up by the

investigator:

Step1 – Researcher introduces herself and explain the purpose of the study to the

subjects.

Step2 – Administration of pretest on knowledge regarding neonatal jaundice.

Step3 – Introduces structured teaching programme.

Step4 – Administration of post test on knowledge regarding neonatal jaundice. The study

period is 4-6 weeks.

10 DESCRIPTION OF TOOL

As per the expert opinion structured knowledge questionnaire will be

prepared. It will consists of:

1: Socio demographic data.

17

2: A structured knowledge questionnaire will be prepared to assess the knowledge of

staff nurses regarding neonatal jaundice.

11. METHOD OF DATA ANALYSIS:

Data will be analyzed by using descriptive and inferential statistics method:

(a)Descriptive statistics such as frequency, percentage, mean, standard deviation and

paired‘t’ test

(b) Inferential statistic: Chi- square test will be used to find out the association between

selected demographic variables with the level of knowledge among the study participants

12. DOES YOUR STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTIONS TO CONDUCT ON PATIENTS OR OTHER

HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY.

Yes, structured teaching programme will be administered to staff nurses regarding

neonatal jaundice.

13 ETHICAL CONSIDERATIONS TOWARDS SAMPLE RELATED

TO STUDY

Yes, written permission will be obtained from Medical Officer of Mediscope Hospital.

18

14. LIST OF REFERENCES :( Vancover style)

1. Thor WR Hansen”Jaundice, neonatal”2009May4.

2. Burke BL et al “Trends in hospitalizations for neonatal jaundice and kernicterus

in the united states”(2009) Feb;123(2):524-32.

3. Hockenberry MJ, Wilson D. Wong’s nursing care of infants and children. 8th

edition. New Delhi: Mosby; 2009.

4. Gupta R. Neonatal surgical jaundice revisited 4th edition .Delhi: Jaypee. 2005.

5. Mary Fran Hazinski. Nursing care of the critically ill child. Princeton, Mosby

publication.1st edition.1984.

6. Marlow R Dorothy and Redding, A. Barbara.Text book of pediatric nursing.

Tokyo, W B Saunders company.6th edition.1998.

7. Avery G B Fletcher and Mac Donald M G, Neonatology pathology and

Management of newborns. Mosby publications, London. 1994.

8. Achar and Vishwanath, Book of pediatrics, Orient hangs man, Bombay, 2nd

edition.1992.

9. Suraj Gupthe, The short text book of pediatrics. Jaypee publications, Newdelhi.9 th

edition.2001.

10. Whaley and Wong. Essentials of pediatric nursing, Mosbypublications,Elsevier,St

Louis. 7th edition 2004.

11. Robertson. Text book of Neonatology. Churchill living stone, Tokyo, 2nd

edition.1992.

12. Joshua Aderinsola Owa, Titus A. Ogunlesi “ Exchange transfusion for neonatal

jaundice in Nigeria”. 2009 Jan 27;(5):51-5 .

13. Sridevi Sukumar et al “Molecular basis of glucose-6-

phosphatasedehydrogenase(G-6-PD)

14. deficiency in India”, Mumbai. 2004 July 30;33 (2):140-5.

15. Bhat,Y Ramesh “ Management of neonatal hyperbilirubinemia”. Manipal,

Karnataka. India. 2007; 21 (1).

16. Swarna Rekha Bhat et al “Dehydration and hypernatremia in term healthy

neonates”. Koramangala, Bangalore. 2007 NOV 25.

19

17. Moerschel SK et al “A practical approach to neonatal jaundice”.2008May;

77(9):1255-62

18. Rose N “Jaundice – the newborn babies”2009Aug 26.

19. David Evans “Neonatal jaundice”.2007Jun 1

20. Kedar PS “Redcell pyruvate deficiency in neonatal jaundice in India”. India J

Ped. 2006 Nov; 73 (11): 985-8.

21. Agarwal V et al “Maternal and neonatal factors affecting physiological jaundice

in western U.P” , Meerut . 2007 Jun; 51 (2) : 2006-6.

22. Fu WP, Liu Y “Role of genetic facrtors in occurance of neonatal jaundice in

Guangxi region”, China. 2005 Oct ; 43(10) : 743-7.

23. Ranjankumar Pejaver and Janaki Viswanath “An audit of phototherapy units”

Vijayanagar, Bangalore.2007 Oct 17;883-4.

24. Ossamu Osaku N, Silvero Lopes H “Phototherapy of the newborn; predictive

model for the outcome”, Brazil.2005,7:6725-8.

25. Boyd S “Treatment of physiological and pathological neonatal jaundice”. 2004

Aug;100(33):45.

26. Olusanya BO, Somefun AO, “ Sensorineural hearing loss in infants with neonatal

jaundice in Lagos : a community based on study” , Nigeria.2009 Jun ; 29(2): 119-

28.

27. Z Shah MD et al “MRI in Kernictrus” Mumbai, India.2008 Sep22.

28. Bhutani VK et al “Kernicterus : epidemiological strategies for its prevention

through systems based approaches”, Philadephiea, 2009 Oct ; 24(10): 650-62.

29. R Keren et al, “Visual assessment of jaundice in term and late preterm infants” ,

2009 March.

30. M J Yaffe et al, “Better care and better teaching .New model of post partum care

for early discharge programs”

31. D Kumar, Averma K Sehgal, National mortality in India and Rural and remote

health vol 7, ICMR,Jabalpur,MP,India.2007.

32. Elizabeth Jean Dickenson, Infant nursing care. Mosby publications. 2nd

edition.1994.

20

33. Behrman, Richard, Nelsons text book of pediatrics. Saunderscompany,

Philadelphia, 16th edition.2008.

34. Tikmani SS , Warraich HJ, Abbasi F, Rizvi A, Darmstadt GL. Incidence of

neonatal hyperbilirubinemia, Pakistan. 2010 May;15(5):502-7.www.pubmed.com

35. Kedar PS, Warang P, Colah RB, Mohanty D, Red cell pyruvate kinase deficiency

in neonatal jaundice cases in India, Institute of Immuno haematology, Indian

Council of Medical Research, K.E.M. Hospital Campus, Parel, Mumbai,

India.2006 Nov;73(11):985-8.

36. Shah I, Bhatnagar S, Clinical profile of chronic hepatobiliary disorders in children

of Western India.Department of Pediatric Medicine and Pediatric Surgery,

Hepatobiliary Clinic, B. J. Wadia Hospital for Children, Parel, Mumbai-400012.

2010 Apr-Jun;31(2):108-10.

37. Fok TF, Lau SP, Hui CW. Neonatal jaundice: its prevalence in Chinese babies

and associating factors. 2006 Aug;22 (3):215-9.www.ncbi.org.

38. Agarwal V, Singh V, Goel SP, Gupta B. Maternal and neonatal factors affecting

physiological jaundice in western U.P. Department of Physiology, Lala Lajpat Rai

Memorial Medical College, Meerut. 2007 Apr-Jun; 51(2):203-6.

39. Usatin D , Liljestrand P, Kuzniewicz MW, Escobar GJ, Newman TB. Effect of

neonatal jaundice and phototherapy on the frequency of first-year outpatient

visits. Albert Einstein College of Medicine, Bronx, New York, USA. 2010 Apr;

125(4):729-34.

40. Brewster DH , Tucker JS, Fleming M, Morris C, Stockton DL, Lloyd

DJ, Bhattacharya S, Chalmers JW. Risk of skin cancer after neonatal

phototherapy. Scottish Cancer Registry, Information Services Division, NHS

National Services Scotland. 2010 Oct;95(10):826-31.

21

9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE

11 11.1 NAME AND DESIGNATION OF GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12

12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE

22