RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Mrs. V.VIJAYALAKSHMI
I year M.sc Nursing
Medical Surgical Nursing
Year 2008-2009
PADMASHREE INSTITUTE OF NURSING
NAGARBHAVI CIRCLE
BANGALORE - 560 072.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. NAME OF THE CANDIDATE AND ADDRESS
Mrs.V.VIJAYALAKSHMI.I year M.sc Nursing,Padmashree Institute of Nursing,Nagarbhavi circle,Bangalore-560 072.
2. NAME OF THE INSTITUTION
Padmashree Institute of Nursing, Bangalore.
3. COURSE OF THE STUDY AND SUBJECT
I year M.Sc Nursing,Medical Surgical Nursing.
4. DATE OF ADMISSION TO THE COURSE
30th June 2008
5. TITLE OF THE STUDY Assessment of effectiveness of planned teaching programme onknowledge regarding dietary management among patients with cirrhosis of liver.
1
6. BRIEF RESUME OF THE INTENTED WORK
6.1 INTRODUCTION
The word “cirrhosis” derives from Greek word “kirrhos” meaning tawny.
(The orange yellow colour of the diseased liver). Rene Laennec who gave the
name cirrhosis in 1819.1
Cirrhosis is ranked as the ninth leading cause of death in the United States
and the fourth leading cause of death in persons between 35 and 54 years of age.2
Cirrhosis is slowly progressive diseases causing irreversible scarring and
nodularity of liver in response to chronic injury from a variety of causes. This
process distorts the normal liver architecture, interferes with blood flow through the
liver and disrupts the bio-chemical function of the liver.3
The majority of cirrhosis of liver are caused by excessive alcohol
consumption, the condition is referred to as alcoholic cirrhosis and other causes are
obstruction of the bile ducts, virus, auto immune hepatitis, prolonged constrictive
pericarditis, decompensated corpulmonale, infiltratative diseases such as
amyloidosis, glycogen storage diseases, hemochromatosis. Alcohol cirrhosis is also
called portal or nutritional cirrhosis is usually associated with alcohol abuse. The
change is uncomplicated accumulation of fat in the liver, potentially reversible if the
person stops drinking alcohol. If the alcohol abuse continues widespread scar
formation occurs throughout the life.4
There are four types of cirrhosis of liver as follows, Alcohol cirrhosis or
nutritional cirrhosis, Post necrotic cirrhosis, Biliary cirrhosis and Cardiac cirrhosis.
It’s characterized by nausea vomiting changes in bowel habits, pain and enlargement
2
of liver and spleen and slight weight loss. Later manifestations are skin lesions,
jaundice, and hematological problems like leucopenia, anemia, thrombocytopenia,
and spider angiomas.5
In cirrhosis, the liver functions are identified by enzymes levels including
alkaline phosphates, Alainin amino transferase, activated clotting time, Y-Glutamyl
trans peptidases are initially elevated. The prothrombin time is prolonged and
bilirubin metabolism is altered. Liver biopsy may be performed to identify liver cell
changes and alterations in the lobular structure. Paracentesis may be helpful in
establishing a diagnosis.6
Cirrhosis changes the structure of the liver and blood vessels that nourish it. The
disease reduces the liver ability to manufacture proteins and process hormone,
nutrition’s and medications. Cirrhosis gets worse over the time and can become
potentially life threatening. Complications of cirrhosis of liver are variceal bleeding,
spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatorenal syndrome,
hepatic encephalopathy and hepatopulmonary syndrome, excessive bleeding,
Impotence, Liver cancer, Coma due to accumulated ammonia and body wastes, liver
failure and leads to death. Proper dietary management may help to prevent or delay
complication, reduce hospitalization and improve survival.7
Cirrhosis of liver is treated with administration of B-complex vitamins.
diuretics, dietary pattern and liver transplantation. The diet for the patient with
cirrhosis without complications is high in calories (3000Kcal/day) with high
carbohydrate content and moderate to low fat levels. Low protein diets were
routinely recommended for patients with cirrhosis in hopes of decreasing intestinal
ammonia production and preventing exacerbations of hepatic encephalopathy.
Sufficient carbohydrate intake must be provided to maintain a minimum intake of
1500-2000 calories to prevent hypoglycemia and catabolism. Glucose polymer is
protein free and can be used as source of calories. It can be given orally or
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nasogastric tube. The patient with ascites and edema is on a low sodium diet. The
degree of sodium restrictions varies depending on the patient’s condition. The
patient needs instruction regarding degree of restriction. The patient should be
advised to read the labels. Foods high in proteins usually have large amounts of
sodium.8
"A healthy liver is very soft, while a liver with early disease begins to
stiffen. A liver with cirrhosis, advanced liver disease, can be rock hard".9
6.2 NEED FOR THE STUDY
The risk of death due to cirrhosis is increased twelve fold, if one excludes the
direct consequences of the liver disease, there is still a fivefold increased risk of
death in all disease categories. Studies have recently suggested that coffee
consumption may protect against cirrhosis, especially alcoholic cirrhosis.10
The increasing prevalence of obesity and the metabolic syndrome increases the
incidence of cirrhosis secondary to nonalcoholic fatty liver disease especially in
developed countries. Cirrhosis of liver is important causes of morbidity and
mortality in the world.11
Nutrition is important in the management of cirrhosis, a well balanced diet
including plenty of fruits, vegetables, milk can allow for optimal function of liver
cells. Excessive protein intake should be avoided especially in patients with more
advanced disease. Cirrhotic patients must completely avoid alcohol and they have to
take only lean proteins such as fish, sea food, chicken breast, red meats, black beans,
barely or cracked wheat. Good sources of vitamins, minerals and antioxidants that
help the liver detoxify and heal. Patients with cirrhosis should avoid eating
uncooked shellfish, which may carry organism that can cause cirrhosis or other
diseases.12
4
Individuals with cirrhosis are at risk for many potential complications.
Complications can be managed or detected early with proper management. The most
lethal of these complications is bleeding, esophageal varices and ascites. Ascites can
be treated with dietary modifications and a diuretic regimen.13
Studies reported that patients with cirrhosis had a 4-year mortality of >60%.
Nutrition intervention has been shown to play a positive role. Recent studies have
indicated anti-alpha therapy, alternative medicinal agents such as milk thistle and S-
adenosylmethionine may be effective in cirrhosis. Treatment of the complications of
liver disease can improve the quality of life and in some cases decrease short-term
mortality.14
Nutritional management for patients with cirrhosis is difficult and nutritional
care hasn’t been established yet at present. Since the number of liver cancer patients
by appropriate nutritional care is very important for the treatment of liver cancer at
present, basic clinical research is expected to grow in the future.15
Approximately 20% patient with chronic hepatitis C and 10% to 20% of those
with chronic hepatitis B will develop cirrhosis.
In 2001several studies were compared to determine the effectiveness of milk
thistle in treating cirrhosis and other liver diseases. The active component of milk
thistle, silymarin, promotes liver protein synthesis. Studies show that improved
survival among cirrhosis patients who use milk thistle.16
Clinical and biochemical signs of protein-calorie malnutrition are associated
with liver disease. Malnutrition increases the number of complications and makes
patient's prognosis worse. Early started nutritional support is an important medical
strategy to limit malnutrition and to maintain liver functions.17
5
A comparative study was done on Nocturnal nutritional supplementation. A
total of 103 patients (68 male, 35 female) were randomized to receive daytime and
nighttime supplementary nutrition (710 kcal/day). Primary etiology of liver disease
was chronic viral hepatitis (67), alcohol (15), cholestatic (6), and other diseases (15).
Total body protein was measured by neutron activation analysis at baseline, 3, 6,
and 12 months. The findings suggested that no significant changes in total body
protein in the daytime group. Daily energy and protein intakes at 3 months were
higher than at baseline in both groups (P < 0.0001) and these changes did not differ
between the groups. The study concluded that provision of a nighttime feed to
patients with cirrhosis results in body protein accretion equivalent to about 2 kg of
lean tissue sustained over 12 months. This improved nutritional status may have
important implications for the clinical course of this patients.18
The investigators own personal experience in the clinical area where she had
come across many patients with cirrhosis of liver and the nutritional problems faced
by these patients, prompted her to take this problem for her research.
6.3 STATEMENT OF THE PROBLEM
6
A study to assess the effectiveness of planned teaching programme on
knowledge regarding dietary management among patients with cirrhosis of
liver in selected hospitals, Bangalore.
6.4 OBJECTIVES OF THE STUDY
1. To assess the existing knowledge regarding dietary management among
patients with cirrhosis of liver.
2 .To assess the post test knowledge regarding dietary management among
patients with cirrhosis of liver.
3. To assess the effectiveness of planned teaching programme regarding dietary
management among patients with cirrhosis of liver.
4. To associate the post test knowledge regarding dietary management among
patients with cirrhosis of liver with their selected demographic variables.
6.5 OPERATIONAL DEFINITIONS:
1. Effectiveness
It refers to the extent to which planned teaching programme regarding dietary
management improves the knowledge among patients with cirrhosis of liver.
2. Planned teaching programme
It refers to systematically developed instructional aids regarding dietary
management among patients with cirrhosis of liver.
7
3. Knowledge
It refers to awareness and level of understanding among patients with
cirrhosis of liver as measured by a structured questionnaire.
4. Dietary management
It refers to conservative and therapeutic dietary measures taken by
patients with cirrhosis of liver.
5. Patients
It refers to the persons who are suffering from patients with cirrhosis of
liver problems and admitted in medical wards of selected hospitals,
Bangalore.
6. Cirrhosis of liver
It refers to slowly progressive disease, causing irreversible scarring and
nodularity of the liver.
6.6 ASSUMPTIONS
1. Patients with cirrhosis of liver may have inadequate knowledge regarding
dietary management.
2. Planned teaching programme may improve the knowledge regarding dietary
management among patients with cirrhosis of liver.
3. Patients knowledge regarding dietary management among patients with
cirrhosis of liver may vary with their selected demographic variables.
8
6.7 RESEARCH HYPOTHESES
H1 – There is a significant difference between the mean pre-test and post-test
knowledge regarding the dietary management among patients with
cirrhosis of liver.
H2- There is a significant association between posttest knowledge regarding
dietary management among patients with cirrhosis of liver with their
selected demographic variables.
6.8 REVIEW OF LITERATURE
A literature review discusses published information in a particular subject
area, and sometimes information in a particular subject area within a certain time
period.19
A descriptive study conducted on liver cirrhosis on nutritional support,
represents the final stage of many chronic liver diseases. These patients have
decreased carbohydrate utilization and storage capacity and increased protein and fat
catabolism leading to depletion of protein and lipid reserves. They concluded that
nutritional therapy brings benefits in the different stages of the disease, it improves
nitrogen balance, decreases the hospital stay, improves liver function, it decreases
the incidence, severity of encephalopathy and improves quality of life.
Supplementation with enteral nutrition may improve protein intake, decrease the
frequency of hospitalization, improve the nutritional status, the immune function
and the disease severity.20
A comparative study was done on Ammonia impairs neutrophil phagocytic
function in liver disease. The study was to determine ammoniagenic diet in patients
9
with cirrhosis, results in neutrophil dysfunction. They concluded that Ammonia
produces neutrophil swelling and impairs neutrophil phagocytosis. The p38
intracellular signaling pathway has been shown to be important in mediating the
ammonia-induced neutrophil dysfunction.21
A descriptive study conducted on malnutrition in end stage liver disease and it
recommends the nutritional support. They found that malnutrition has increasingly
acknowledged as an important prognostic factor, which can influence the clinical
outcome of patients suffering from end-stage liver disease. Malnutrition should alert
clinicians to the same extent, as do other complications such as ascites and hepatic
encephalopathy. Enteral nutrition improves nutritional status and liver function,
reduces complications, prolongs survival and is therefore indicated.22
A study was done on many patients with chronic alcohol abuse present a
clinical picture of malnourishment, because of reduced intake of essential nutrients
precludes an appropriate digestion and absorption of the different essential elements,
vitamins, and minerals. It interferes with normal metabolism. Nutritional supports
may be effective to improve alcoholic liver disease. A balanced diet, vitamin
supplements, and pharmacological therapy with antioxidants in order to recover
depleted glutathione deposits are recommended.23
A descriptive study was done on Nutrition in liver cirrhosis. Malnutrition is
highly prevalent among patients with liver cirrhosis. A reduced nutritional status,
i.e., protein energy malnutrition, has prognostic significance resulting in increased
morbidity and mortality rate. The result concluded that a sufficient daily energy
supply should be guaranteed in patients with cirrhosis of liver the increased turnover
of amino acids requires a sufficient protein supplementation. Additional substitution
of vitamins and trace elements is indicated when symptoms of deficiency are
apparent. Nutritional advice in patients with cirrhosis requires an individual
management regarding the dominating complications of the disease.24
10
An experimental randomized study conducted on Branched-Chain Amino Acid.
For 48 patients with cirrhosis of liver received late-evening supplementation with
the branched-chain amino acid -enriched nutrient mixture, for 3 months. For
another group they had given ordinary food, such as a rice ball or bread, for 3
months. The result shows that serum albumin level, nitrogen balance, and
respiratory quotient were significantly improved by the branched-chain amino acid
mixture but not by ordinary food. They concluded that long-term oral
supplementation with it branched-chain amino acid mixture better than ordinary
food in a late evening snack in improving the serum albumin level and the energy
metabolism in patients with cirrhosis.25
An experimental study conducted on obesity increase the risk for liver
cancer in patients with cirrhosis of liver and long-term oral supplementation with
branched-chain amino acid granules inhibits liver carcinogenesis in heavier patients
with cirrhosis of liver. The result shows that the risk for liver cancer was
significantly higher for males, patients with an alpha-fetoprotein level of 20ng/mL
or higher and patients with higher body mass index. They concluded that, the risk
for liver cancer was significantly reduced in the group with a body mass index of 25
or higher and with an alpha-fetoprotein level of 20ng/mL or higher. Oral
supplemental treatment with branched-chain amino acid may reduce the risk of liver
cancer in cirrhotic patients.26
A study conducted on dietary antioxidant compounds and liver health,
founded that Chronic liver damage is a widespread pathology characterized by a
progressive evolution from steatosis to chronic hepatitis, fibrosis, cirrhosis, and
hepatocellular carcinoma. The study suggests that the use of antioxidants have been
proposed as therapeutic diet like lycopene-rich foods. Alpha-tocopherol, beta-
carotene, Quercetin, silymarin, esculetin and thyme are maintaining the liver
health.27
11
An experimental study conducted on the impact of carnitine on serum
ammonia concentration and lipid metabolism in patients with alcoholic liver
cirrhosis suggested that Carnitine taking part in liver lipid metabolism might be a
potentially effective drug. And result show a significant improvement was observed
in the group of patients treated with L-carnitine L-aspartate (p < 0.003), and among
those treated with L-isocarnitine (p = 0.005). L-carnitine lowers the serum ammonia
concentration and improves lipid metabolism.28
7. MATERIALS AND METHODS
7.1 SOURCES OF DATA
The data will be collected from the patients with cirrhosis of liver who are
admitted in medical wards of selected hospitals, Bangalore.
7.2 METHODS OF DATA COLLECTION:
i. Research design:
Quasi experimental - one group pretest posttest design.
ii. Variables:
Dependent variables: level of knowledge on dietary management among
patients with cirrhosis of liver.
Independent variables: Planned teaching programme on dietary management
among patients with cirrhosis of liver.
iii. Setting:
Medical wards of selected hospitals, Bangalore.
iv. Population
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All patients with cirrhosis of liver admitted in medical wards.
v. Sample:
Patients with cirrhosis of liver who fulfill the inclusive criteria will be
considered as samples and the sample size is 60.
vi. Criteria for sample selection
Inclusive criteria:
The study includes:
1. Both male & female patients with diagnosis of cirrhosis of liver.
2. Patients who can understand kannada / English.
3. Patients who are willing to participate
Exclusive criteria:
The study exclude:
1. Patients who have developed complications like liver cancer, liver failure.
vii. Sampling technique:
Non – probability convenience sampling technique.
viii. Tools for data collection:
The tool consists of two sections:
Section A: Demographic data includes age, gender, educational status,
occupation, family income, dietary habits, personal habits like smoking,
alcohol, exercise, disease condition, sources of information.
13
Section B: Structured questionnaire will be used to assess the knowledge
regarding dietary management among patients with cirrhosis of liver.
ix. Method of data collection
After obtaining, the permission from concerned authorities and informed
consent from the samples, the data will be collected in three phases:
Phase I: A pre-test will be conducted to patients with cirrhosis of liver using a
questionnaire to assess their knowledge regarding dietary management.
Phase II: A planned teaching programme on dietary management will be
conducted for 45mts on the same day immediately after the pretest.
Phase III: After an interval of seven days, a posttest will be conducted for the
sample using the same questionnaire for evaluating the effectiveness of
planned teaching programme.
x. Plan for data analysis
The data collected will be analyzed by means of descriptive statistics and
inferential statistics.29
Descriptive statistics: Frequency, percentage distribution, mean, and standard
deviation will be used to analyze the level of knowledge regarding dietary
management among patients with cirrhosis of liver.
Inferential statistics: Paired‘t’ test will be used to compare the pretest and
posttest knowledge. Chi-square test will be used to analyze the association
between posttest knowledge regarding dietary management among patients with
cirrhosis of liver with their selected demographic variables.
xi. Projected outcome:
14
This study will help to assess the existing knowledge of patients with cirrhosis of
liver on dietary management. Administration of planned teaching programme
will help to improve the patient’s knowledge on dietary management and its
significance in preventing the further complaints of cirrhosis of liver.
7.3 Doest the study requires any investigation or interventions to be
conducted on patients or other human or animals?
Yes, planned teaching programme will be administered as an intervention for the
patients with cirrhosis of liver.
7.4 Has ethical clearance been obtained from your institution?
Yes, permission will be obtained from concerned authority of the hospital .The
informed consent will be obtained from the samples. Confidentiality and
privacy of data will be maintained.
8. LIST OF REFERENCES
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Wikipedia.com.
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Cirrhosis of liver. New Delhi: Elsevier; 2007 P. 1102.
3. Suzannec.Smrltzer, Brunner & Suddarth. Textbook of Medical Surgical
Nursing. Cirrhosis of liver. Philadelphia: Lippincott foren publishers; 1996.
P.1102.
4. B.T. Basavanthappa. Medical Surgical Nursing. Cirrhosis of liver. New Delhi:
Jaypee brothers; 2003. P. 303-04.
5. Joyce M. Black. Medical Surgical Nursing. Cirrhosis of liver. New Delhi: Saunders Elsevier; 2001: p.1336-38.
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55(3); P.403-08.
7. Barbara K Timby, Nancy K Smith. Introduction to Medical Surgical Nursing.
Cirrhosis of liver. USA: Williams & Wilkins; 2007. P. 878-92.
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9. Eureka Alert. A Broad spectrum of liver disease. Available from URL\http\\
health.surfwax.com\files\cirrhosis.
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epidemiology. 2007/May/15; 56: (1); P. 88–93.
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11. Lim YS, Kim WR. The global impact of hepatic fibrosis and end-stage liver
disease. Clinical Liver Disease. 2008/Nov;12:(4); P. 733-46.
12. Mörk H. Basics of nutrition in cirrhosis of the liver . Kreiskrankenhaus
Nagold .2007 Apr 26;149(17): P.33-4.
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2005;23:(3-4): P.275-84.
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intolerance:JJPEN.2000\JAN\8;22(6); P.395-400. Available from URL:/
http://science links japan.com.
16. Walsh, Nancy. Milk Thistle for Liver Disease. Internal Medicine
News:2002/Jan/1; 10(4); P.11-3. Available from URL:/http:// www.tibotec-
virology.com .
17. Kulig G. Nutritional therapy in stable liver cirrhosis: 2000;57(3); P.168-70
18. Plank LD , Gane EJ, Peng S, Muthu C, Mathur S, Gillanders L, McIlroy K,
Donaghy AJ, McCall JL. Nocturnal nutritional supplementation improves
total body protein status of patients with liver cirrhosis: Hepatology.
2008/Aug;48:(2); P. 557-66
19. Polit F Denise and Cheryl Tatano beck. Nursing research. Review of
literature: New Delhi: Lippincott publication; 2008. P. 105-07
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20. Mesejo A, Juan M, Serrano A. Liver cirrhosis on nutritional support: 2008
/feb/23;5(2); P.8-18. Available from URL/ http//www. [email protected] .
21. Shawcross DL, Wright GA, Stadlbauer V, Hodges SJ, Davies NA.
Ammonia impairs neutrophil phagocytic function in liver disease:2008
Oct;48(4): P.1202.
22. Tsiaousi ET, Hatzitolios AI, Trygonis SK, Savopoulos CG. Malnutrition in
end stage liver disease, recommendations and nutritional support: J
Gastroenterol Hepatol: 2008 Apr; 23(4): P.527-33.
23. Moreno Otero R, Cortes JR. Nutrition and chronic alcohol abuse. Nutr
Hosp. 2008;23(2); P.3-7.
24. Gundling F, Teich N, Strebel HM, Schepp W, Pehl C. Nutrition in liver
cirrhosis. 2007 Jun 15;102(6): P.435-44.
25. Nakaya Y, Okita K, Suzuki K, Moriwaki H, Kato A, Miwa Y, BCAA-
enriched snack improves nutritional state of cirrhosis. 2007 Feb;23(2):
P.113- 20. URL:/http://www. [email protected] .
26. Muto Y, Sato S, Watanabe A, Moriwaki H, Suzuki K, Kato A, Kato M.
Overweight and obesity increase the risk for liver cancer in patients with liver
cirrhosis and long-term oral supplementation with branched-chain amino acid.
Epub 2006 Jul;35(3): P.204-14.
27. Vitaglione P, Morisco F, Caporaso N, Fogliano V. Dietary antioxidant
compounds and liver health.2004;44(7-8):P.575-86.
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28. Łapiński TW, Grzeszczuk A.Klinika Obserwacyjno-Zakazna Akademii
Medycznej w Białymstoku. The impact of carnitine on serum ammonia
concentration and lipid metabolism in patients with alcoholic liver cirrhosis.
2003 Jul;15(85):P.38-41.
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9. Signature of the candidate :
10. Remark of the guide :
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11. Name and designation of guide :
11.2. Signature :
11.3. Co-guide :
11.4. Signature :
11.5. Head of the department :
11.6. Signature :
12.1. Remarks of the principal :
12.2. Signature :
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