INTRODUCTION:

Anticoagulant therapy is the administration of a medication to delay the clotting time of blood, to prevent the formation of a thrombus, and to forestall the extension of a thrombus once it has formed. Anticoagulant therapy is indicated in patients with thrombophlebitis, patients suspected of recurrent embolus formation, those with persistent leg oedema secondary to heart failure, post-operative patients and the elderly patients who are likely to be immobilized for a long time. It is very important to monitor the patients receiving anti-coagulant therapy just as important to control diet and other factors in life. Anticoagulants are one of most common types of medications in use today and help prevent and treat a wide variety of health conditions.

Anticoagulants may be divided into direct anticoagulants such as Heparins and indirect anticoagulants such as the Coumadin. In general anticoagulants are used in the management and prophylaxis of thromboembolic disorders. Pulmonary embolism alone kills 60,000 people every year. Often clots form in the legs; break free and travel to the lungs where then can cause sudden fatal condition known as pulmonary embolism.Despite major advances in the treatment of MI and unstable angina the rate of recurrent events in this population remains high. Almost 0.5 million patients with a prior MI have a recurrent infarction. In the year after a MI, the subsequent rate of mortality is 10%¹.The most common and frequently used oral anti-coagulant is Coumadin (Warfarin). They need to be monitored very closely because a little too much or too little can seriously alter the effectiveness of Coumadin, which is why frequent monitoring of the anti-coagulant level in the blood is essential.

NEED OF THE STUDY:

Anticoagulation medications are high-risk drugs. There is a very small window for therapeutic dosing: too much of a drug can cause bleeding, and too little may lead to clotting. So the nurses and the nurse practitioners should be provided with knowledge and skills necessary to prevent patient harm associated with anticoagulant therapy. They should be taught how to: identify common indications for use of anticoagulants, describe monitoring requirements, consider important safety implications to help prevent complications, and discuss patient/family educational needs related to anticoagulants².

In 2008, The Joint Commission published a new National Patient Safety Goal (NPSG) to address high-risk anticoagulation drugs used for treatment. This Goal, with an implementation date of January 2009, required organizations to develop and implement standardized practices in order to reduce harm. While the NPSG applies to all anticoagulants, special focus is made on the most commonly used anticoagulants: Unfractionated heparin (UFH), Low molecular weight heparin (LMWH), Warfarin ( Coumadin) Anticoagulation drugs can be life-saving. Nurses must carefully assess, closely monitor, and comprehensively educate the patient receiving anticoagulation drugs to ensure the full benefit of anticoagulation therapy and to minimize potential harm. Patients on anticoagulant therapy must be educated about their increased risk for bleeding, monitoring for bleeding, managing bleeding if it occurs, and drug-specific information³.Gras-Champel et al, in their study recommends teaching the patients to recognise the signs and symptoms of adverse effects, especially bleeding. Intracranial haemorrhage is the most lethal and serious adverse effects of oral anticoagulant therapy⁴.

A study done by Spader found the need to return to the hospital for repeated laboratory monitoring is a key factor in oral anticoagulation management.Schulman in his study stressed that diet therapy is an important aspect of oral anticoagulant therapy. Patients must be taught which foods are high in vitamin K content and how to balance their diets to avoid single episodes of high consumption of vitamin K rich foods which can change their INR range easily⁵. A study conducted by Wahl MJ, showed that basic teaching such as using a soft tooth brush, dental follow-up, using an electric shaver, and carrying medical identification is important. Patients need to be instructed when to call medical professionals about cuts that do not stop bleeding or fail to heal or prolonged bruising. Patients and their family members will need to be taught how to give a subcutaneous injection, the importance of proper needle disposal, and the reason for the prolonged therapy⁶. Gaspar states that patients need to seek medical care immediately. Patients also must be instructed the signs and symptoms of possible GI bleeding such as coffee ground emesis, dark tarry or red stools, weakness, dizziness, thirst and abdomen pain⁷. Keeping in mind all these factors, the investigator realized how important it is to assess the knowledge and practices of nurses in the administration of anticoagulants.

STATEMENT OF THE PROBLEM:

Effect of planned teaching on knowledge and practice regarding the care of patients receiving anti-coagulant therapy among the nurses in the intensive care unit in a selected hospital.

OBJECTIVES:

1. To assess the knowledge of nurses before and after the planned teaching.

2. To assess the practices of nurses before and after the planned teaching.

3. To find the association between the knowledge and practice of nurses with selected demographic variables.

ASSUMPTIONS:

1) Knowledge and practices of nurses may vary depending upon their years of experience.

2) Nurses may have some knowledge about anticoagulation therapy.

3) Planned teaching may enhance their knowledge and improve their practicing skills.

HYPOTHESIS:

Ho: There will be no significant difference in the pre- test and post-test mean knowledge score of nurses in the intensive care unit on anti-coagulant therapy.

DELIMITATIONS:

1. The sample is limited to the nurses who are working only in the intensive care unit of a selected hospital.

2. Effect of knowledge and practice will be done only through self administered structured questionnaire and observation checklist.

SCOPE OF THE STUDY:

1) The present study will provide with the acquisition of knowledge on anticoagulation therapy for nurses.

2) The structured knowledge questionnaire will provide lot of input on oral, subcutaneous and intravenous administration of anticoagulants.

3) The planned teaching will serve as a guide in continuing education for nurses working in the intensive care units and to the educators to teach to the nursing students.

4) The observation checklist will help nurses and nursing students to develop professional skills to administer the anticoagulant drugs.

5) This study can be used by the Nursing Administrators to prepare a protocol for care of patients on anticoagulation therapy.

6) The study results can be added to the references and further studies can be conducted based on this study.

ETHICAL CONSIDERATIONS:

i. Research proposal was presented before the ethical committee and duly approved by them.

ii. Permission for conducting the study was obtained from the Executive Director of the hospital.

iii. Sisters-in-charge of the departments were informed about the study in order to gain co-operation.

iv. Informed consent was taken from the participants after explaining the purpose of the study.

v. The participants were allowed to withdraw from the study if needed.

REVIEW OF LITERATURE:

The review of literature of the study is divided into 6 areas:

1 Study Related to Anticoagulation Therapy:

Post-cardiac surgery at rial fibrillation (AF) places patients at risk for thromboembolism and stroke, while the surgery and cardiopulmonary bypass alter the multiple factors of coagulation and may increase the tendency to bleed. It is in the context of this complex clinical picture that the physician must make decisions regarding the risks and benefits of anticoagulation therapy to lower the risk for thromboembolism and stroke associated with postoperative AF⁹.

The Sixty Plus Rein Fraction Study Group found that anticoagulant therapy in elderly patients after a MI reduced 2 years total mortality from 13.4% with placebo to 7.6% with anticoagulants. The incidence of MI was also reduced from 15.9% to 5.7% with anticoagulant therapy. Nine times as many patients had major haemorrhagic episodes with anticoagulant therapy⁸. If A trial Fibrillation persists for more than 48 hrs, patients should receive anticoagulation therapy with warfarin to achieve an international normalized ratio of 2.0 to 3.0 as recommended for non-operative patients by the ACC/AHA/ESC guideline. Because of the bleeding risk associated with Heparin, Warfarin therapy may be started without Heparin. Although the optimal duration of therapy has not been established, and normal sinus rhythm returns, anticoagulation therapy can reasonably be stopped because its risks outweigh the potential benefits. Nevertheless, delaying the cessation of anticoagulation therapy for 1 month after the return of sinus rhythm may be prudent since it has been demonstrated that impaired a trial contraction, with a presumably enhanced risk for thrombosis, can persist for several weeks after AF ceases¹².

Fenq D et al (2009) in their study on intra cardiac thrombosis and anticoagulants in cardiac amyloidosis states that the cardiac amyloid patients, especially in the AL type and in those with a trial fibrillation risk for thrombosis increased if left ventricular diastolic dysfunction and a trial mechanical dysfunction were present. Anticoagulation therapy is safe and should be considered carefully. Timely screening in high-risk patients may allow early detection of intra cardiac thrombus¹⁰.

2 Studies Related to Warfarin Therapy:

A study to assess cardiology nurses knowledge about warfarin therapy states that Forty-one questionnaires were given to 94 registered nurses. Nurses did not demonstrate a good understanding of warfarin therapy. Knowledge deficits were identified across a broad spectrum of areas, with only 30% of nurses reporting that they felt equipped to provide families with education regarding oral anticoagulant therapy. Nurses regularly provide patients with education regarding medication regime, however, the effectiveness of that education is rarely evaluated. This study suggests that nurses working with patients who are often prescribed oral anticoagulant therapy have significant knowledge deficits about anticoagulant therapy¹¹.

The Post Coronary Artery Bypass Graft (Post-CABG) study sought to determine whether low dose Warfarin (mean INR of 1.4) was better than placebo in preventing progression of atherosclerosis in vein grafts. There was difference in the angiographic outcome of patients treated with Warfarin at 4 year follow up. The study found improved vein graft patency with use of Warfarin, especially 2 years after bypass surgery, although there was also an increased rate of significant bleeding events¹³.

Warfarin is indicated in patients with a trial fibrillation, mechanical heart valves, previous thrombosis or previous embolism. Retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) trial suggested improved survival for patients on warfarin. Data are favourable for patients with visible LV thrombi and known factors predisposing the stasis of blood flow (e.g. a trial fibrillation). A prospective study on anticoagulant-associated haematuria revealed that major disease in 30% of patients, including malignancy in four. In another prospective evaluation, 29 patients taking anticoagulants developed haematuria. A retrospective review of 24 patients taking Warfarin and 69 patients taking Aspirin who developed gross haematuria showed major disease in 69 (74.1%) patients¹⁴.

A study on subjects treated with Warfarin after heart valve replacement, who were randomized to receive an initial dose of either 2.5mg or 5mg of Warfarin showed that the lower dose was more effective. Gage examined the use of nomograms and computer modelling for Warfarin dosing. He suggests that a patient with a baseline INR of 1, who achieves an INR greater than 1.5 obtained 15 to 24 hours after the initial dose, will require a very low daily dosage of warfarin (1mg). If the INR is 1.2 to 1.3 the patient will require a low daily dosage (2mg to 3mg) and a second dose of 5mg should be given. If the INR remains 1 to 1.5 after second dose of 5mg, a higher dose (7.5mg) can be given¹⁵.

A study on warfarin maintenance dosing in clinical practice indicated that the median dose for men with AF, aged 60-69 was 4.6 were as for women it was 4. For men aged 70-79 the median dose was 4.3, versus 3.5 for women and for men aged 80-89 it was 3.9, versus 3.2 for women. Gage suggests INR testing be done 15 hours or more following administration of the first dose. Warfarin should be administered in the afternoon if the INR monitoring is done the following morning, if warfarin administered in the evening, INR monitoring should occur the following afternoon¹⁵.

Schulman states that diet therapy is an important aspect of oral anticoagulant therapy. Warfarin considered a vitamin K antagonist. Patient must be taught which food items are high in vitamin K content and has to balance their diets to avoid single episodes of high consumption of vitamin K rich foods which can change their INR range easily¹⁴.

3 Studies Related to Heparin Therapy:

A serious side-effect of Heparin is Heparin-induced thrombocytopenia (HIT). HIT is caused by an immunological reaction that makes platelets a target of immunological response, resulting in the degradation of platelets. This is what causes thrombocytopenia. This condition is usually reversed on discontinuation, and can generally be avoided with the use of synthetic Heparins. There is also a benign form of thrombocytopenia associated with early Heparin use, which resolves without stopping Heparin. In September 2006, Heparin received worldwide publicity when 3 prematurely-born infants died after they were mistakenly given overdoses of Heparin at an Indian apolis hospital¹⁶. Unfractionated Heparin is the cornerstone for the treatment of acute venous thromboembolism. Although Heparin is highly effective, it is always associated with some risk of haemorrhage. Published reports also have described failures of Heparin therapy caused by sub therapeutic doses. When Heparin is given by continuous IV infusion and the dose is regulated with an appropriate clotting time test, the incidence of serious haemorrhage is reduced and therapeutic efficacy is assured¹⁷.

Chenella et al. has described a method for determining initial Heparin infusion rates based on the patient's blood volume. Heparin has been dosed with an IV bolus dose of 5,000 to 10,000 units of Heparin, followed by an infusion of 1,000 units per hour. Others have advocated that a more rational method of initiating therapy is to begin with a loading dose of 50-100 units/kg of Heparin followed by a constant infusion of 15-25 units/kg/hr¹⁸.

4 Studies Related to LMWH Therapy:

Upchurch et al. reported in the New England Journal of Medicine, on the use of LMWH as VTE prophylaxis in trauma patients, that there is a wealth of Class I data supporting the use of LMWH as VTE prophylaxis in orthopedic surgery. This literature is derived primarily from total hip and knee replacement patients. Overall, LMWH appears to be equivalent or superior to UH for prophylaxis in general surgery patients. Most data in many different types of patients confirm improved efficacy of LMWH with the same or even less bleeding risk compared to UH prophylaxis. LMWH should be the standard form of VTE prophylaxis in trauma patients with complex pelvic and lower extremity injuries as well as spinal cord injuries¹⁹.

Farnett E.L in the study LMWH preferred for Pulmonary Embolism evaluated the efficacy of low-molecular-weight heparins (LMWH) in the treatment of symptomatic or asymptomatic pulmonary embolism (PE). By combining the data in a meta-analysis, the authors hoped to increase the power of the studies to show a difference between unfractionated heparin (UFH) and LMWH in the treatment of acute PE. From an extensive search of the literature, 34 potential trials were identified, 12 of which that met the criteria of a randomized controlled clinical trial, using LMWH administered subcutaneously, compared with intravenously administered Unfractionated heparin (UFH) in the treatment of symptomatic or asymptomatic PE. These 12 studies included 1,951 patients with pulmonary embolus. This meta-analysis presents the strongest evidence to date that LMWHs are a viable and effective treatment of non-massive pulmonary embolism.²⁰ Eliano Pio Navarre et al. in their paper published on 20^th July, 2011 in a new meta-analysis has found that low-molecular-weight heparins (LMWHs) are associated with a reduction in mortality and major bleeding rates in STEMI patients treated with primary PCI as compared with unfractionated heparin (UFH). And patients at greatest risk seem to derive the most benefit from LMWHs²¹.

Cohen M. in his study, “The role of low-molecular-weight heparin in the management of acute coronary syndromes”, consistently demonstrated that low-molecular-weight heparin (LMWH) compounds are effective and safe alternative anticoagulants to unfractionated heparins (UFHs). They have been found to improve clinical outcomes in acute coronary syndromes and to provide a more predictable therapeutic response, longer and more stable anticoagulation, and a lower incidence of UFH-induced thrombocytopenia. Enoxaparin is the only LMWH compound to have demonstrated sustained clinical and economic benefits in comparison with UFH in the management of unstable angina/ non–ST-segment elevation myocardial infarction (NSTEMI)²².

Gilles Montalescot et al. in their publication on, “Low Molecular Weight Heparin after Mechanical Heart Valve Replacement” stated that patients with mechanical heart valves require life-long anticoagulation therapy. In this comparative, nonrandomized study, 208 consecutive patients who underwent a single or double heart valve replacement with mechanical prostheses were anticoagulated subcutaneously with Unfractionated heparin (UH) in the first period (n=106) and LMWH in the second phase (n=102) of the study. Baseline characteristics were similar in the 2 groups. On the second day of treatment, 87% of patients treated with LMWH had an anti-Xa activity within the range of efficacy but only 9% of UH-treated patients had an activated partial-thromboplastin time value within the therapeutic range (1.5 to 2.5 times control, P<0.0001 between the 2 groups). So in this comparative study, anticoagulation with LMWHs after mechanical heart valve replacement appears feasible, provides adequate biological anticoagulation²³.

5 Studies Related to Anticoagulation Therapy in Children:

Two well-conducted pharmacokinetic studies in this age group showed that neonates and younger infants require higher LMWH doses than older children to achieve the targeted anti-Xa levels, due to an increased extra vascular clearance. Hainer et al, have demonstrated several benefits of low-molecular-weight heparins (LMWH) over UFH, which are at least as effective as UFH. The frequency of bleeding complications and heparin-induced thrombocytopenia is significantly lower. An important advantage stems from the fact that the pharmacokinetics of LMWH is more predictable than those of UFH, thus, frequency of monitoring via anti-factor Xa assays can be minimized²¹.Schobess et al. commented that Pharmacokinetic studies in children are sparse and have indicated that the LMWH Enoxaparin can be administered subcutaneously twice or once daily to prevent symptomatic thromboembolism in children at risk²⁴.Michaels LA et al, in the study on, “Low molecular weight heparin in the treatment of venous and arterial thrombosis in the premature infants showed improved survival rate in the smallest and sickest infants. Treatment with low molecular weight heparin (LMWH) has potential advantages, including predictable pharmacokinetics, subcutaneous administration, and minimal monitoring²⁵.

A study conducted by PREVAIL (Prevention of VTE after Acute Ischemic Stroke with LMWH Enoxaparin) study demonstrated a significant 43% reduction in venous thromboembolism (VTE) events with Enoxaparin vs. Unfractionated heparin (UFH) in medically-ill patients who suffered an acute ischemic stroke⁷⁴. Among medically-ill patients, stroke patients are at an increased risk for developing VTE. Without VTE prophylaxis, up to 75% of patients with hemiplegia following stroke develop deep-vein thrombosis (DVT) and 20% develop pulmonary embolism (PE)²⁶.

6 Studies Related to the Elderly Patients:

Anticoagulation in the elderly is a growing concern as patients live longer and have an increasing number of co-morbid illnesses. Given the increased risk of venous thromboembolism (VTE) with normal aging, it is important to understand the therapeutic and prophylactic options available.Aging is a well-established risk factor for VTE, and elderly patients experience higher morbidity and mortality with this disease. In a large community-based study in France, the incidence of symptomatic VTE was 1.83 per 1000 persons. This figure rises to 10 per 1000 persons for those over the age of 75. A study examining the incidence of asymptomatic deep venous thrombosis (DVT) in geriatric patients admitted to a medical service showed that 4% of patients aged 70 to 80 and nearly 18% of patients aged over 80 had evidence of DVT²⁷.

In a recent study of warfarin induction in elderly in-patients, most of whom had acute venous thromboembolic disease, a 4mg dose was given for the first day of treatment. The dosage was then adjusted according to the INR on day 3 through the use of an algorithm, which predicted the maintenance dose with a low rate of over anti-coagulation. In addition to aging, numerous other factors are noted to increase the risk of thrombosis. These include hospital stay, surgery, central venous access catheters, pacemakers, and chemotherapy and hormone therapy. Patient specific risk factors include congestive heart failure, myocardial infarction, stroke and malignancy within the preceding 6 months of an event. Also included as risk factors are prior thrombosis, hypercoagulable states, COPD, hip fractures, trauma, varicose veins, paralysis of lower limbs, obesity, nephritic syndrome and severe infection²⁸.

Fihn et al. studied the 3- year cumulative incidence of bleeding reported from 5 outpatient sites where Warfarin was being monitored in 928 patients. The minor bleeding rate was 17.3 events per year. Serious bleeding rate was 7.5; life threatening bleeding was 1.1 and fatal bleeding 0.2 events per 100 patients per year. One half of the serious, life threatening or fatal bleeding episodes were in gastrointestinal tract. Of these with a serious or life threatening bleeding episode, 32% had another episode of bleeding, typically within the first year after the index event. Risk factors for bleeding were INR more than 2, newly initiated therapy, variability of the INR over time, and 3 or more comorbid conditions²⁹.

Hylek and Singer specifically focused on the risk for intracranial haemorrhage in a case control study of 121 patients. The degree of anticoagulation was expressed as the prothrombin time ratio (PTR) instead of the INR. The PTR was the dominant predictor of subdural and intracranial haemorrhage. Age was an independent predictor for subdural bleeding but was of only borderline significance for intracranial haemorrhage.³⁰ Pulmonary embolism has a wide spectrum of clinical presentation, from subtle clinical signs to hemodynamic instability resulting in death within an hour of acute onset. In most cases, PE goes undetected and is a ‘silent’ killer identified only at autopsy. An analysis of 200 autopsied cases showing massive or sub massive PE performed between 1989 and 1995 revealed that in 78% of cases , major PE had not been diagnosed by physicians^31,33.

Patients with valve disease often require oral anticoagulation because of the risk of systemic embolization due to a trial fibrillation (AF) or to prevent emboli developing on mechanical prosthetic valves. Increasingly patients with prosthetic heart valves are also being prescribed concomitant antiplatelet therapy to increase the efficacy of the anticoagulation (reduced risk of death or thromboembolic events), with an acceptable increase in the risk of major bleeding³².

RESEARCH METHODOLOGY:

RESEARCH APPROACH:

In order to accomplish the main objectives of the study, a descriptive evaluative approach was selected. Descriptive approach was used to assess the knowledge and practice of nurses in the intensive care units regarding the care of patients receiving anticoagulation therapy. Evaluative approach was used to test the effectiveness of teaching module.The study was conducted in four phases. In phase-1, pre-test data was collected by administering the questionnaire and the observation check list, phase-11 planned teaching was given, phase-111 post test data was collected by using questionnaire and observation checklist and phase-1V was the data analysis.

RESEARCH DESIGN:

The research design is the backbone or the structure of the study as it provides a framework that supports the study and holds it together. In the study, one group pre-test post-test design was adopted, where the group was assessed with the structured questionnaire and observation checklist, before and after administration of the independent variable e.g. planned teaching. This design helped the researcher to study the change in the knowledge and practice of nurses in the intensive care units before and after introducing the planned teaching on selected aspects of anticoagulation therapy.

VARIABLES:

Independent Variables:

An independent variable is the variable that has the presumed effect on the dependent variable (Wood and Haber, 1994). In this study the independent variable is planned teaching on anticoagulation therapy.

Dependent Variable:

A dependent variable is the variable the researcher is interested in understanding, explaining or predicting (Polit and Hungler, 1994). In this study it refers to the knowledge and practice of nurses regarding the anti-coagulant therapy.

Extraneous Variables:

Extraneous variables are those uncontrolled variables (variables not manipulated by the experimenter) that may have a significant influence upon the results of a study (Best and Kahn, 1992). In this study the extraneous variables are age, qualification, designation, clinical experience in the ICU and in-service education programmes on Anticoagulation therapy.

SETTING OF THE STUDY:

The study was conducted in a selected hospital, with a bed strength of 280. It is a multi-specialty hospital and a research centre. It has specialized departments such as ICU, ICCU, SICU, well equipped Heart Institute, Cardiology Unit, Medical Surgical departments, Orthopaedic, Urology, Nephrology, Ophthalmology, E.N.T, Gynaecology, psychiatry, Neurology, Paediatric, Neonatology, Pathology and Physiotherapy department. The hospital has 12 beds in the ICCU, 7 beds in ICU and 8 beds in the SICU. The nurse patient ratio, 1:1 is maintained in these areas.

POPULATION:

In the present study, population consisted of all senior staff nurses working in all the ICU, ICCU and SICU during the period of data collection.

SAMPLE AND SAMPLING TECHNIQUE:

The sample consisted of 30 staff Nurses who were working in the ICU, ICCU and SICU units of a selected hospital and who met the inclusion criteria. Non probability convenient sampling technique was adapted for the selection of samples in this study.

TOOLS AND TECHNIQUES:

The tools consisted of structured knowledge questionnaire to assess knowledge on anticoagulation therapy, planned teaching module on anticoagulation therapy and an observation checklist to assess the practice of nurses regarding the care of patients receiving anticoagulant therapy in the intensive care units.

RELIABILITY OF THE TOOL:

The reliability of the tool was tested on three staff nurses of a selected hospital. The reliability of the questionnaire was done using test retest method. Cronbach’s Alpha formula was used to find out the reliability of the full test. The reliability of the tool was found to be r = 0.928 (structured knowledge questionnaire) and r = 0.789 (observation checklist) which indicated that the tool was reliable.

The calculated t value was then compared with the table value at p=0.05 significance level. The formula used for correlated small group to calculate level of significance.

Mean

t = ------------

SEMD

Where,

t = level of significance.

Mean D = Mean difference of pre and post test score.

SEMD (standard error of mean difference) = S.D. /√n

S.D. = Standard deviation

N = 30

Before calculating ‘t’ value Null Hypothesis (H0) and alternate Hypothesis was stated. The two tailed ‘t’ value for 0.05 level of significance was 2.04

H0 – There is no difference in the mean of pre-test and post-test knowledge and practices after administration of planned teaching on anticoagulation therapy.

The calculated value was found to be 12.68 for knowledge and 12.46 practice score for oral anticoagulation therapy, 18.15 for subcutaneous LMWH injections and 17.75 for the administration of I.V Heparin injections. As the calculated value was greater than the table ‘t’ value at 0.05 level, suggesting that the planned teaching was effective in increasing the knowledge and practice level, null hypothesis (H0) was rejected and research hypothesis was accepted for both knowledge and practice of the subjects.

CONCLUSION:

This shows that there was a significant difference in the mean of pretest and post-test knowledge and practice scores of the sample. Therefore it was concluded that there was a significant difference at 0.05 levels with regard to the knowledge and practice regarding the selected aspect of care of patients on anticoagulation therapy in the pre-test and post-test. Thus the null hypothesis (H₀) is rejected in both knowledge and practice. These results support the significance of planned teaching in the improvement of knowledge and practice of nurses in the selected aspect.

Frequency and percentage are used to analyse the sample characteristics. Area wise range, mean, median and standard deviation were also used to analyse the scores. The effectiveness of the planned teaching was assessed by test re-test method. The association between knowledge and practice score with selected demographic variable was assessed by ANOVA method using Cronbach’s alpha formula.

Anti-coagulants are one of the most common types of medications in use today and help to prevent and treat a wide variety of health conditions. Pulmonary embolism alone kills 60,000 people every year. So it is very important for a nurse to monitor the patients receiving anti-coagulant therapy just as important to control diet and other factors in life. Anticoagulant therapy have been used for preventive treatment of arterial and venous thrombo embolism in major orthopaedic surgery, as well as primary prevention of MI, in the high risk population and systemic embolism in patients with rheumatic mitral valve prolapse, long periods of immobility, obesity, vascular access usage, and hypercoagulability.

Patients to be instructed about the need for a temporary lower dose of their anticoagulant therapy before surgery or possibly discontinuing their oral anticoagulant in favour of alternative drugs such as heparin or LMWH before elective surgery. The nurses need to teach the patients to recognise the signs and symptoms of adverse effects, especially GI bleeding such as coffee ground emesis, dark tarry or red stools, weakness, vomiting, headache, dizziness, and thirst and abdomen pain. Patients also need basic teaching about strategies to decrease their potential for bleeding such as using a soft tooth brush, avoiding flossing their teeth, scheduling appropriate dental follow up, using electric razor and carrying medical identification.

So the nurses and the nurse practitioners should be equipped with knowledge and skills necessary to prevent complications associated with anticoagulant therapy. They should be taught how to: identify common indications for use of anticoagulants, describe monitoring requirements, consider important safety implications to help prevent complications, and discuss patient/family educational needs related to anticoagulants. Hence the researcher felt the need to undertake this study.

DESCRIPTION OF THE TOOLS:

Tool 1: A structured knowledge questionnaire on anticoagulants consisting of 30 items, to assess the knowledge of nurses regarding anticoagulation therapy

Tool 2: An observation checklist, to assess the practice of nurses on oral, subcutaneous and intravenous administration of anticoagulants.

Tool 3: A planned teaching module is on anticoagulation therapy.

The steps involved in the development of instruments were preparation of questionnaire, observation checklist, planned teaching module, and content validation, pretesting and testing for reliability using Cronbach’s alpha method. Reliability of the tool was estimated and found to be r = 0.928 (knowledge questionnaire) and r = 0.789 (observation checklist) which suggested that the tool was highly reliable. The main study was conducted on 30 subjects in four phases. In phase-1 pre-test data was collected by administering the questionnaire and the observation check list, phase-11 planned teaching was given, phase-111 post test data was collected by using questionnaire and observation checklist and phase-1V was the data analysis.

RELIABILITY OF THE TOOLS:

To test the reliability test re-test interater method is used.

DATA ANALYSIS:

1. Frequency distribution, frequency percentage and ‘t’ test

2. Data analysis by descriptive and inferential statistics

3. Association between the demographic variables in the form of tables and graphs.

FINDINGS OF THE STUDY:

1. Majority of the subjects (90%) were in the age group of 21-25 years.

2. Majority of the subjects (76%) were qualified as GNM’s.

3. Most of them (83%) were junior staff nurses.

4. 60% of the subjects had only 6 months to one year of clinical experience.

5. Most of the subjects (80%) had no previous clinical experience in the intensive care units.

6. None of the subjects had attended any in-service education programmes earlier.

Knowledge on Anticoagulants:

· Majority of the participants were aware that anticoagulants prevent thrombosis as they scored 96.7% in pre-test and 100% in post-test.

· Most of the subjects (9) scored above 50% in the post test which shows that the planned teaching was effective.

· Overall post-test knowledge scores were higher as compared to pre-test knowledge score.

· Anticoagulants are indicated for an indefinite period in patients with A trial Fibrillation was answered by only one (3.3%) in pre-test and 10 subjects (33.3%) scored right in post-test.

· Most of the subjects (6 out of 10) scored above 70% and in the best time to take Warfarin is in the evening scored 100% in post-test.

· Post-test knowledge score was excellent compared to pre-test knowledge score which shows that planned teaching was effective.

· Patient on LMWH should test Anti factor X a level scored only one (3.3%) in pre-test and 9 (30%) scored correct in post-test.

· Majority of the subjects had excellent knowledge in the post test compared to the pre-test knowledge scores.

· Method of switching over to Heparin 7 days prior to surgery and restart after surgery no one scored right in pre-test and in post-test 24 (80%) scored correct.

Practice of subjects on the administration of oral anticoagulants:

· On administration of oral anticoagulants it showed that the subjects post-test practice score was higher as compared with pre-test practice score except consulting the physician or sister-in-charge whenever any doubts in the administration of oral anti-coagulants, nurses scored 100% in booth pre-test and post-test.

· The mean percentage practice score of post-test were higher ranging from 57 to 97% in all the areas of practice whereas the mean percentage of practice score in pre-test were ranging from 33-87%

Practice of Subcutaneous Administration of LMWH Injections

· In the administration of subcutaneous LMWH injections the pre-test practice scores were much lower than the post test scores. None of the sample scored correct in the pre-test practice in cleaning the injection site with alcohol swab in circular motion from the centre to outward and allows to dry and in post-test scored 36.7%.

· In two areas like hand washing and holding the syringe in the dominant hand during the administration of injections all the subjects scored 100% in both pre-test and post-test practice.

· It showed that none of the subjects were aware that massaging at the injection site can cause bleeding during the pre-test practice whereas in post-test practice scores were 56.7%. Overall post-test practice scores were higher as compared to pre-test practice score. Also it shows two practices were correctly followed by all subjects during the pre-test as well as post-test that is all the subjects were aware that the needle should not be recapped and the needles to be discarded in a puncture proof container after the procedure.

Practice on administration of I.V Heparin:

· Practice score of pre-test in checking for the side effects of Heparin therapy such as bleeding gums, haematuria, and maleena was nil, whereas in post-test the practice score in this area was 60%.

· In the practice of hand washing all the subjects followed correct practice in the pre-test and post-test as well. Also in the practice of cleaning the top of the vial with the spirit swab.

· In administration of I.V. Heparin, infusion pump rate should not be altered until the next APTT result is known and observing the client for adverse reactions scored nil in pre-test whereas in post-test the scores were 33.3% and 36.7% respectively.

· With draws the medication as per the prescribed dosage all the subjects (100%) followed the correct practice in both pre-test and post-test.

Effect of Planned Teaching on Knowledge:

· The mean pre-test and post-test knowledge scores were 13.73 and 21.77 respectively

· The calculated ‘t’ value (12.68) was greater than the table value of 2.04, which suggests that the planned teaching was effective in increasing the overall knowledge of the samples.

· Hence null Hypothesis (Ho) was rejected and research Hypothesis was accepted showing that there is a significant difference between the mean pre-test and post-test knowledge scores of the subjects.

Effect of Planned Teaching on Practice:

· The calculated value was found to be 12.68 for knowledge and 12.46 practice score for oral anticoagulation therapy, 18.15 for subcutaneous LMWH injections and 17.75 for the administration of I.V Heparin injections.

· As the calculated value was greater than the table ‘t’ value at 0.05 levels, suggesting that the planned teaching was effective in increasing the knowledge and practice level, null hypothesis (H0) was rejected and research hypothesis was accepted for both knowledge and practice of the subjects.

IMPLICATIONS OF THE STUDY:

Nursing Administration:

The nurse administrators can use the planned teaching as a structured teaching to improve the knowledge of the nurses and to ensure that the nurses take responsibility and accountability while caring for the patients on anticoagulation therapy. Regular in-service education programmes to be conducted for nurses to improve their knowledge and skills to ensure better professional standard of nursing.

Nursing Service:

Nursing services are involved not only in the curative but also with the preventive, promotive and rehabilitative role as well. The study revealed that individuals are in need of knowledge and skills in practice in order to be effective in caring the individuals under our care. This study can help the staff to gain more knowledge and improve the skills in the administration of anticoagulants. The study would provide guidelines for the nurses in educating the patients while on anticoagulation therapy. The study would also help in bringing about awareness among the nurses to prevent the complications of drug therapy and to watch for adverse effects while on anticoagulants.

Nursing Education:

This study can be helpful for the nurse educators, as they play a significant role in motivating and educating the student nurses. Nurse educators need to know about the guidelines, side-effects, dosage, tests and its normal values and complications of anticoagulation therapy. The planned teaching was effective to increase the knowledge and practice of nurses in the intensive care units Nursing in-service education programmes need to be conducted regularly in the hospitals. The results of the study can be used by nursing educators as an informative illustration to nursing students.

Nursing Research:

The methodology, tools and findings of the study have added to the existing body of the knowledge in the nursing profession. There is need for extended and intensive nursing research in the field of anticoagulation therapy among the nurses as well as patients to prevent the complications Future investigators may utilize the suggestions and recommendations for conducting further studies The present study may serve as a reference material for the students

RECOMMENDATIONS:

A similar study may be replicated on a larger scale. A comparative study could be done to assess the effectiveness of other teaching modalities like self-instructional module, information booklets on the same topic. The same study could be done among patients on anticoagulants to assess their knowledge on anticoagulation therapy. The same study can be done with a control group. The study can be conducted over a longer period of time to assess the effectiveness of planned teaching in reducing the complications of patients on anticoagulants.

CONCLUSION:

This study has helped to assess the knowledge and practice of nurses in the intensive care units taking care of patients on anticoagulation therapy. The study reveals that it is important to have regular in-service education programmes for nurses to improve their knowledge and practice skills while caring for the patients in order to impart quality care and prevent undue complications during the drug therapy. Knowledge and practices of staff nurses in the intensive care units on anticoagulants were inadequate before the teaching module was administered. There was no significant association between gain in knowledge and practice score with the selected demographic variables.

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Received on 26.02.2015 Modified on 10.03.2015

Asian J. Nur. Edu. and Research 5(3): July- Sept.2015; Page 351-362

DOI: 10.5958/2349-2996.2015.00072.5

Sr. No.	Knowledge score				MD	SEMD	Calculated ‘t’ value
1	Pre-test		Post test		8.03	0.63	12.68
	M1	SD1	M2	SD2
	13.73	3.49	21.77	3.52

Sr. No.	Practice Type	Practice score				MD	SEMD	‘t’ value
		Pre test		Post test
		M1	SD1	M2	SD2
1.	ORAL ANTICOAGULANTS	10.23	1.38	13.4	1.07	3.16	0.25	12.46
2.	LMWH INJECTIONS ( SUBCUTANEOUS)	13.03	1.67	19.4	1.54	6.36	0.35	18.15
3.	ADMINISTRATION OF I.V HEPARIN	11.30	1.20	16.03	1.42	4.73	0.26	17.75

Effect of Planned Teaching on knowledge and practice regarding the care of patients receiving Anti-Coagulant Therapy among the Nurses in the Intensive Care Unit in a Selected Hospital.

OBJECTIVES: To assess the knowledge and practices of nurses before and after the planned teaching and to find the association between the knowledge and practice of nurses with selected demographic variables.

FINDINGS OF THE STUDY:

· It showed that none of the subjects were aware that massaging at the injection site can cause bleeding during the pre-test practice whereas in post-test practice scores were 56.7%.

· Practice score of pre-test in checking for the side effects of Heparin therapy such as bleeding gums, haematuria, maleena was nil, whereas in post-test the practice score in this area was 60%.

· In administration of I. V. Heparin, infusion pump rate should not be altered until the next APTT result is known and observing the client for adverse reactions scored nil in pre-test whereas in post-test the scores were 33.3% and 36.7% respectively.

· The mean pre-test and post-test knowledge scores were 13.73 and 21.77.

· The calculated ‘t’ value (12.68) was greater than the table value of 2.04, which suggests that the planned teaching was effective.

· The calculated value was found to be 12.68 for knowledge and 12.46 practice score for oral anticoagulation therapy, 18.15 for subcutaneous LMWH injections and 17.75 for the administration of I.V Heparin injections.

Practice of subjects on the administration of oral anticoagulants: