PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DISSERTATION PROPOSAL

TOPIC: - A STUDY TO EVALUATE THE EFFCEIVENESS OF STRUCTURED

TEACHING PROGRAMME REGARDING KNOWLEDGE ON EARLY CORONARY ANGIOGRAPHY AND ITS BENEFIITS IN PREVENTING THE CARDIAC COMPLICATIONS AMONG CARDIAC PATIENTS AT SELECTED HOSPITALS TUMKUR.

SUBMITTED BY MR. SAJESH STEPHEN GEORGE Ist YEAR MSc NURSING, (2011-12) MEDICAL SURGICAL NURSING, SHRIDEVI COLLEGE OF NURSING, TUMKUR - 572106

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA.

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ANNEXURE-II SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DESSERTATION

NAME OF THE CANDIDATE AND ADDRESS

MR. SAJESH STEPHEN GEORGE SHRIDEVI COLLEGE OF NURSING, SIRA ROAD, TUMKUR. - 572106

NAME OF THE INSTITUTE

SHRIDEVI COLLEGE OF NURSING,TUMKUR

COURSE OF STUDY AND SUBJECT

Ist YEAR MSc NURSING MEDICAL SURGICAL NURSING

DATE OF ADMISSION TO COURSE

01/07/2011

TITLE OF THE TOPIC

A STUDY TO EVALUATE THE EFFCEIVENESS OF STRUCTURED TEACHING PROGRAMME ON EARLY

REGARDING

KNOWLEDGE

CORONARY ANGIOGRAPHY AND ITS BENEFIITS IN PREVENTING THE CARDIAC

COMPLICATIONS AMONG CARDIAC PATIENTS AT SELECTED HOSPITALS TUMKUR.

6. BRIEF RESUME OF THE INTENTED WORK INTRODUCTION Early Coronary Angiography Improves Long-Term Survival in cardiac disease - American Heart Foundation
Todays world is facing coronary artery disease as a leading cause for the mortality and morbidity in the present era, both in developed and developing countries. In India great strides have been made in the preceding decades in the diagnosis and treatment of coronary artery disease, including resort to high tech solutions for the prevention of coronary artery diseases. Today more and more stress is laid on the preventive aspects of the coronary artery diseases and its complications since there is a high prevalence of coronary artery disease and other cardiac disorders among the population12. World Health Organization (WHO) has reported that, approximately 50 million death occur throughout the world every year with almost 80 % of these (40 million) occurring in developing countries due to cardiovascular disease. It has been estimated that approximately one quarter of all deaths in developing countries and half of all deaths are due to cardiovascular diseases. Among cardiovascular disease s Coronary Artery Disease (CAD) is the leading disease causing high mortality and morbidity. WHO report stated that coronary disease accounted for more than 8 million deaths worldwide. In industrialized countries CAD is responsible for 1/3 rd total deaths.3 Early diagnosis and risk stratifying of patients at the onset of clinical disease has become extremely important in the present scenario. The major risk factors responsible for the development of cardiac diseases are high level blood lipids, smoking, hypertension, obesity and sedentary life styles. These have been directly related to increased mortality among post myocardial infarction patients. Coronary angiography is defined as the radiographic
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visualization of the coronary vessels after injection of radiopaque contrast media. It is most commonly performed with specialized intravascular catheters. The procedure is usually included as part of cardiac catheterization, which may also involve angiography of other vascular structures, such as the aorta and left ventricle.10 The purpose of coronary angiography is to define the coronary anatomy and the degree of luminal obstruction of the coronary arteries. It is most commonly used to determine the presence and extent of obstructive coronary artery disease (CAD) and to assess the feasibility and appropriateness of various forms of therapy, such as revascularization by percutaneous or surgical interventions. It is also used when the diagnosis of coronary disease is uncertain and coronary disease cannot be reasonably excluded by noninvasive techniques25. The risk of major complications is <2%, but factors such as the stability of the patient's condition, the presence of shock, acute renal insufficiency, and cardiomyopathy significantly increase risk. A number of relative contraindications to the procedure have been reported. Of these, preexisting renal failure, particularly in a patient with diabetes, and a history of prior anaphylactic reaction to contrast medium require special attention before coronary angiography to reduce the risk of subsequent complications.25 Cardiac catheterization was performed in >1 000 000 patients in 1993, making it the second most frequent in-hospital operative procedure performed in the United States. Approximately 48% of all catheterizations are performed in patients 65 years. The use of catheterization continues to grow. Given the predicted growth in population and aging of the population, it is possible that by 2010. About 3 000 000 procedures will be performed annually in the United States. The striking variations in use of coronary angiography in the United States have led to concerns about its appropriateness. A number of studies have evaluated this issue, and the

results suggest that the incidence of inappropriate use of coronary angiography is relatively low, ranging from 4% to 18%.10 The task force of American Heart Association has recommended angiography as the definite tool in early detection of coronary artery disease for selected patients. American college of cardiology (1999) emphasized the need for educational approach for the prevention and early diagnostic evaluation of coronary artery disease. Coronary Angiography is a diagnostic procedure used in the evaluation of patients suspected with Coronary Artery Disease or valvular diseases. Nearly after 50 years after invention of coronary Angiography is still considered as the gold standard procedure for the defining the coronary anatomy and to visualize atherosclerotic coronary artery disease. Performing coronary angiography after cardiac symptoms can be useful in obtaining prognostic information as well as details of the coronary anatomy and there by helps to treat the underlying cause.22 The last few decades have seen an advancement of research in the methods of diagnosing and treating and controlling the coronary artery disease. In 1929 Werner Forssmann exposed a vein in his left arm and introduced a ureteric catheter and advanced it under the fluoroscope and placed in to the right atrium. Credits must be given to Cournand and ranges (1941) and Richard (1945) who carried out a series of original investigations into right side of the heart and pulmonary artery in human heart. Further development of various cardiac and coronary procedures came rapidly, in 1959 selective coronary arteriography was reported as an excellent technique and it was modified into percutaneous approach by rickets and Abram in 1962 & 1967.23 Patients with coronary artery disease have a lot of scope for secondary prevention and risk mitigation if the prognosis is early detected by early coronary angiography. This is successful in bringing about positive effects like improvement in lifestyle, and compliance with the
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treatment regimen. Nurses have an important role in helping the people affected with cardiac diseases in educating and equipping them to undergo coronary angiography with the necessary information regarding benefits of coronary angiography in early detection of coronary artery disease. 6.1 NEED FOR THE STUDY In 21
st

century, coronary artery disease is emerged as a new epidemic affecting Indians at a

relatively younger age with severe and diffuse forms of lesions. Today the concept of coronary artery disease is a challenge of many research centers at worldwide. Among Indians the risk of coronary artery disease is 3-4 times higher than white Americans, 6times higher than Chinese, and 20 times higher than Japanese. According to Current Science (2006) Indians are prone as a community to coronary artery disease at a much younger age. This is a premature Coronary Artery Disease which is occurring before the age of 55 years in men and 65 years in women. Indians are facing this disease before 40 years of age and showing the higher incidence of hospitalization due to chest pain and other cardiac symptoms.3 Coronary angiography is a unique physiological and psychological experience for the patient. Each patient will be having their own conception about the procedure. And some of them will be having negative aspects because of fear of death. The nurse who knows and understand the step involved in the procedure should instruct the patients with adequate information so as to prevent or minimize the complication and adverse effects of the procedure. The nurse need to equip the patient with adequate knowledge regarding the usefulness of the early coronary angiography in early detection of coronary artery disease there by promoting patients to utilize the best medical cardiac services available. This increased availability of cardiac services may promote the use of procedure irrespective of clinical indications.16

Education programme for the cardiac patients is an essential for the implementation of quality cardiac services. Hence the effectiveness of the coronary angiography is totally depends upon the patient motivation to have a healthy heart.17 Rakel (1992) commented that, patient teaching has always been important component in minimize the risk and complications. 13 Kendali and Rice (1994) conducted a study in heart institute at Canada with 30 patients undergoing invasive procedure of coronary angiography to determine the knowledge and patients anxiety level related to the coronary angiography. The study indicated that the primary information given before the procedure can reduce the anxiety and stress. The patient were very much confident had good communication with the interventional cardiologist and experienced less pain during the procedure.15 Sutherland emphasized about health care instructions to the cardiac patients through health education book. Written materials seemed to be more effective than other form of health education. Well informed and educated patients were more likely to adjust to hospitalization , cope up with stressful procedure , experienced less pain and had minimal complication as well as recover quickly from the surgery.14 Through the review of literature and personal experience with the cardiac cases the researcher realized the deficiency of knowledge among the population and the need of an educational programme for the patient undergoing cardiac procedure especially the invasive procedure like coronary angiography. The present day the individuals wants to know , why , what , how , about the procedure that he has to undergo especially when it is concerned with very important vital organ like heart. By having the knowledge regarding the needs and importance of educating the patients, the investigator felt the urge of providing a structured teaching programme regarding coronary
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angiography and its benefits in preventing the cardiac complication for the patients who are having cardiac diseases.

6.2 REVIEW OF LITERATURE

The purpose of review of literature is to obtain comprehensive knowledge base and in department of information from previous studies. In this study the literature reviewed is presented under the following headings Literature related to prevalence of coronary artery disease ( CAD) Literature related to benefits of early coronary angiography Literature related to effectiveness of educative materials on coronary angiography.

Literature related to prevalence of coronary artery disease ( CAD)

Kain, et al conducted an epidemiological study on 300 migrant south Asians at university of vascular medicine in United Kingdom. The samples were selected by convenient sampling method; the study revealed that, coronary artery disease is the most important risk factor for cardiovascular disease both in urban and rural areas. The average age for the onset of myocardial infarction is 50.2. The study also demonstrated that, silent coronary artery disease was present in 57% males and 79% females.1 Bahl, Prabhakaran and karthikeyan conducted a cross-sectional study in cardiothoracic centre at All India Institute Of medical science, New Delhi with samples of 1000 cardiac patient selected by purposive sampling technique. The findings of the revealed that, the prevalence of coronary artery disease is 7 times more in immigrant Indians as compared to Chinese. The study also estimated the global burden of cardiovascular disease to rise by 103% in men and 90% in women from 1985 to 2015.2

American Heart Association and WHO (2000) reported that, India is on threshold of an epidemic of cardio vascular disease. It accounts to approximately 17% of worlds mortality due to cardiovascular death. Nearly 457 of every 1, 00, 000 deaths in India would occur due to cardiovascular disease in a year. It is expected that, about 534 for every 1, 00,000 deaths would be occur by the year 2015.3

Literature related to benefits of early coronary angiography

Dr. Udo Hoffmann conducted a study to determine the usefulness of coronary computed tomography angiography (CTA) in patients with acute chest pain. The researcher used an observational cohort study in chest pain patients with normal initial troponin and non ischemic electrocardiogram. A 64-slice coronary CTA was performed before admission to detect coronary plaque and stenosis (>50% luminal narrowing). Results were not disclosed. End points were acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events during 6-month follow-up. The study found that , Fifty percent of patients with acute chest pain and low to intermediate likelihood of ACS were free of CAD by computed tomography and had no ACS. Given the large number of such patients, early coronary CTA may significantly improve patient management in the emergency department.4 Varghese conducted need based study on 892 patients with the symptoms of unstable angina and underwent early coronary angiography at Mayo- Clinic, Mount Sinai Medical centre in New York. A total of 2264 patients with symptoms consistent with unstable angina were identified with a mean duration of follow-up of 6 years; 892 underwent early angiography. Early angiography patients were younger; less likely to have heart failure; more likely to be male, hypercholesterolemia, and smokers; had prior coronary revascularization; and had a myocardial infarction at the index presentation. After baseline differences were controlled, early angiography was associated with a reduction in all-cause long-term mortality The
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study results revealed that, early coronary angiography in the patients with unstable angina is associated with a reduction in all causes of mortality, particularly in the intermediate and high risk patients.5 Natarajan conducted a prospective study to determine the risks of awiting coronary angiography at regional centre in Hamilton Ontario. A computerised prospective central waiting list was developed at regional centre consists of 8030 consecutive patients who referred for coronary angiography. Major cardiac outcomes like death, myocardial infarction and congestive cardiac failure were documented during waiting list for coronary angiography. The findings were most of the referral of primary symptoms of coronary artery disease. The median waiting time was ranges fr4om 6 days to 60 days. The study revealed that, out of 8030 patients who were on waiting list, 32 patients had myocardial infarction and 50 patients died and 41 patients developed congestive cardiac failure. The study concluded that, awaiting cardiac angiography might experience major cardiac adverse events such as death, myocardial infarction and congestive cardiac failure.6 Lane and Carroll stated that, psychological stress has been implicated among the patients at the onset and progression of coronary artery disease and also found the effect of early coronary angiography in reducing the stress and anxiety. The study also commented that, depression and anxiety were the independent risk factors of mortality in cardiac patients. It was critical that, clinical levels of distress should be identified both in hospital and after discharge to target patients who required having coronary angiography and specific psychological intervention. This included in modifying the risk factors, compliance with medicine regimen based on angiography result and attendance of educational programme which in turn the cardiac morbidity and mortality.7

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Murray, Farrel and Huston conducted a qualitative study at Ottawa Heart Institute Canada to identify the needs and experience of the womens with coronary artery disease. The study included 500 women aged between 35 to 55 and selected by simple random sampling method. The study found that, all women had difficulties in recognising their symptoms of heart disease and 35% reported that initially they were misdiagnosed to have gastro enteritis. But after undergoing coronary angiography revealed that, the women had coronary artery disease. The study finding emphasized the development of more effective information on coronary angiography and its needs in early identification of cardiac disease.8

Literature related to effectiveness of educative materials on coronary angiography.

Matta conducted a survey at Escort Heart institute and research Centre Delhi to assess the need of educational programme for cardiac patients. The study included 500 cardiac patients with whom the survey was conducted. The study found that, majority 72% of cardiac patients said that they wanted to participate with their physician in decision making about the treatment regimen and the health care. Findings of the study also revealed that, patients were most likely to follow the suggestion related to altering lifestyle, related to risk factors and about coronary angiography and angioplasty. When the message was conveyed by the personal physician. But it is factual that detailed explanation was not given regarding health matters unless specifically asked, which make the patients lack of information about cardiac services available and about their own health aspects.
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Elizabeth studied the role of nurses in educating the cardiac patients using an exploratory approach. A purposive sampling technique was adopted, a sample consists of 1500 staff nurses and the instrument used was a structured knowledge questionnaire. The findings of the study revealed that, majority (60 %) of nurses gave priority on patient teaching about the causes, risk factors, symptoms, early diagnosis and management of cardiac diseases and rest
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(40%) nurses gave supportive educational care. The study showed that structured teaching and the use of specific written guidelines on cardiac diseases for teaching is more effective than unstructured educational programme. The study also revealed that, use of Audio Visual and written aids enhance learning. 10

STATEMENT OF THE PROBLEM

A STUDY TO EVALUATE THE EFFCEIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING KNOWLEDGE ON EARLY CORONARY ANGIOGRAPHY AND ITS BENEFIITS IN PREVENTING THE CARDIAC COMPLICATIONS AMONG CARDIAC PATIENTS AT SELECTED HOSPITALS TUMKUR.

6.3 OBJECTIVES OF THE STUDY

1. To assess the knowledge of Cardiac Patients regarding coronary Angiography and its benefits in preventing the cardiac complications at selected hospitals Tumkur.

2. To develop a Structured Teaching Programme on coronary Angiography and its benefits in preventing the cardiac complications.

3. To assess the knowledge of cardiac Patients regarding coronary Angiography and its benefits in preventing the cardiac complications after structured teaching programme.

4. To compare the knowledge of Cardiac Patients about coronary Angiography and its benefits in preventing the cardiac complications before and after structured teaching programme.

5. To find out the association between the pre test knowledge score with the selected demographic variables of the cardiac patients.

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6.4 OPERATIONAL DEFINITIONS

Evaluate: refers to determine the knowledge gained regarding coronary

Angiography and its benefits in preventing the cardiac complications, after structured teaching programme. Effectiveness: Refers to significant gain in knowledge as determined by significant difference in pre and posttest knowledge scores of cardiac patients .

Structured Teaching Programme (STP): In this study STP means a well prepared teaching programme designed to provide information regarding coronary Angiography and its benefits in preventing the cardiac complications to the cardiac patients.

Knowledge: is defined as the correct responses of Cardiac Patients to the items in

the self-structured interview regarding coronary Angiography and its benefits in preventing the cardiac complications.

Cardiac patients: refers to the individuals who are seeking medical advice for cardiac diseases like Hypertension, coronary artery disease, myocardial infarction, angina and valvular diseases.

Early Coronary angiography: it refers to one of the invasive diagnostic procedure carried out in cardiac catheterization lab to visualize the coronary arteries for the presence of an atherosclerotic plaque immediately when patient experience chest pain.

Cardiac complications: it refers diseases like myocardial infarction. Heart blocks , congestive cardiac failure , cardiac arrest and other cardiac diseases which are resulting due to improper treatment of early coronary artery diseases

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6.5 HYPOTHESIS
H1 : There is significant difference between the pre and posttest knowledge scores of the Cardiac Patients regarding coronary Angiography and its benefits in preventing the cardiac complications H2 : There is a significant association between the pre -test knowledge scores of the Cardiac Patients and the selected demographic variables.

6.6 ASSUMPTIONS
The Cardiac Patients may have minimal knowledge regarding coronary Angiography and its benefits in preventing the cardiac complications. STP provides an opportunity for learning and better understanding regarding coronary Angiography and its benefits in preventing the cardiac complications.

6.7 DELIMITATIONS
The study is limited to the Cardiac Patients who Are visiting and admitted at selected hospitals at Tumkur. Will be present during the period of data collection

Are willing to participate in the study. The sample size is limited to 50 Cardiac Patients who are at selected Hospital. patients who are having cardiac symptoms and medically diagnosed as cardiac patients

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6.8 PILOT STUDY

The pilot study will be conducted with 5 Cardiac Patients and who will be excluded in the main study. The purpose of pilot study is to find out the feasibility of conducting study and design on plan of statistical analysis. The finding s of the pilot study samples will not be included in main study.

6.9 VARIABLES
Research variables are the concepts of various levels of abstractions that are entered manipulated and collected in a study.
Dependent variable: Knowledge regarding coronary Angiography and its

benefits in preventing the cardiac complications

Independent variables: Structured Teaching Programme on coronary angiography and its benefits in preventing the cardiac complications

Demographic Variables: Age, Gender, education qualification , occupation , family income, food habits , history of cardiac illness, sources of information regarding cardiac illness.

7. MATERIALS AND METHOD

This study is designed to assess the effectiveness of STP on knowledge regarding coronary angiography and its benefits in preventing the cardiac complications.

7.1 SOURCES OF DATA

The data will be collected from Cardiac Patients who are seeking medical cardiac services at selected hospitals Tumkur.

7.1.1 RESEARCH DESIGN

The design is selected for the present study is quasi-experimental design in which one group pre and posttest design without control group.

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7.1.2 RESEARCH APPROACH

An evaluative research approach will be used for the present study.

7.1.3 RESEARCH SETTINGS

The study will be conducted at selected hospitals Tumkur where the cardiac patients are getting cardiac services.

7.1.4 POPULATION
The populations for the study are the Cardiac Patients who are having cardiac symptoms and medically diagnosed as cardiac patients seeking cardiac services either by admitting or by visiting at the selected hospitals Tumkur.

7.2 METHODS OF DATA COLLECTION

The data collection procedure will be carried for a period of 3 weeks. The study will be conducted after obtaining permission from the concerned authorities and informed consent from the samples. The data will be collected in three phases. PHASE I: - A pre test will be administered to Cardiac Patients at selected hospitals, Tumkur using a structured questionnaire to assess their knowledge regarding coronary angiography and its benefits in preventing the cardiac complications.

PHASE II: - A structure teaching programme on coronary angiography and its benefits in preventing the cardiac complications will be conducted for about 45 minutes on the same day immediately after pre test.

PHASE III: - After an interval of 7 days a post test will be conducted for the sample using structured questionnaire for evaluating the effectiveness of STP.
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7.2.1 SAMPLING PROCEDURE

Convenient sampling technique will be selected for the present study.

7.2.2 SAMPLE SIZE

The sample comprised of 50 Cardiac Patients seeking cardiac services at selected hospitals and who will be available during the data collection.

CRITERIA FOR SAMPLE COLLECTION 7.2.3 INCLUSION CRITERIA

The cardiac patients Who are visiting and seeking cardiac services on outpatient department basis (OPD) at selected hospitals. Who are having cardiac disease and are admitted for the treatment at selected hospitals. Who are present during data collection. Cardiac Patients who are willing to participate in the study .

7.2.4 EXCLUSION CRITERIA

Non cardiac patients who are visiting or admitted in the selected hospitals. Critically ill cardiac patients.

7.2.5 TOOLS FOR DATA COLLECTION

The types of tools will be used for the study are SECTION A: - A schedule to assess the demographic data of cardiac patients such as Age, Gender, education qualification , occupation , family income, food habits , history of cardiac illness, sources of information regarding cardiac illness.

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SECTION B: -The investigator will develop structured Questionnaire on coronary angiography and its benefits in preventing the cardiac complications.

SECTION C: - STP on coronary angiography and its benefits in preventing the cardiac complications and content validity will be established by requesting the experts to go through the developed tool and give their valuable suggestions.

7.2.6 PLAN FOR DATA ANALYSIS

The data collected will be analyzed by a means of Descriptive and inferential statistics.

(A). IN DESCRIPTIVE STATISTICS: - Mean standard deviations, range, and mean

scores of subject will be used to quantifying the level of knowledge regarding coronary angiography and its benefits in preventing the cardiac complications among cardiac patients.

(B). IN INFERENTIAL STATISTICS;

Paired t - Test will be used to examine the effectiveness of STP by comparing pre and post test scores. And to find out the differences in knowledge between pre and post tests. The Chi Square will be used to find out the association between socio demographical variables of Cardiac Patients with pre test knowledge scores. The data will be planned to present in the form of tables and figures.

7.2.7 TIME AND DURATION OF THE STUDY

The time and duration of the study will be limited to 6 weeks or as per guidelines of university.

7.3

DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENT OR OTHER HUMAN OR ANIMAL? IF SO, PLEASE DESCRIBE BRIEFLY.

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Yes, structured teaching programme on coronary angiography and its benefits in preventing the cardiac complications will be administered as an intervention to the staff nurses.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITITION?

Yes, the pilot study and the main study will be conducted after the approval from the research committee of Shridevi College of Nursing Tumkur. Permission will be obtained from the concerned head of the hospitals. The purpose and details of the study will be explained to the study subjects and an informed consent will be obtained from them. Assurance will be given to the study subjects on the confidentiality and anonymity of the data collected from them.

8. LIST OF REFERENCES
1. Kain, Catto and Grant, epidemiology of cardio vascular risk factors in migrant South Asians. Asian journal of clinical cardiology. 2001; 4 (3): 55-64 2. Bahl, Prabhakaran, and karthikeyan. Coronary Artery Disease in Indians. Indian Heart Journal. 2001; 53: 707 -713. 3. WHO task force on the development of module banks. Self learning material and modules for health workers, A guide for their development utilization and evaluation New Delhi. 1983; 5-14 4. Dr. Udo Hoffmann, prevention of cardiac complications: Am j Crit care; 2004. 13:25 -33. 5. Varghese. , et al. early coronary angiography improves long term survival in unstable angina . American Heart Journal. 2001; 1: 768 -774. 6. Natarajan., et al. The risk of waiting for cardiac catherization: a prospective study. Canadian Medical Association journal. 2000; 167 (11): 1233 -1244.

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7. Lane,

Carroll. et al. Programmed instruction booklet for cardiac rehabilitation teaching.

Heart and Lung. 2001; 20 (6): 648 -653. 8. Murray, Farrel, Huston, Improving written patient education materials a review of the evidence. Health education journal. 2005; 54: 99 106. 9. Matta., Education Programme for cardiac patientsAian journal of cardiovascular nursing. 2001; 3: 17 19. 10. Elizabeth, et al. cardiac catheterization: technique and Teaching. Nursing Clinics of North America. 2004; 11(2): 271- 281. 11. Lahiri, s., rate of intravascular ultrasound in cardiac catheterization laboratory. Cardiology today .2002; 7 94): 390 -405. 12. Sethi, k., Homocystine and cardiovascular disease emerging issues cardiology today. 2001; 5 (3): 151 153. 13. Rakel., Intervention related to patient teachingNursing clinics Of North America. 1992; 27 (2): 397 405. 14. Sutherland., teaching the patient with ischemic heart disease, a systemic Approach to instructional design. Patient counseling and health education .2002; 3 (2): 57 -62. 15. Kendali, Rice. Nurses ability to perceive patients fears related to coronary arteriography. Journal of advanced Nursing. 2001; 28(6): 1225 -1235. 16. Dhawan., Coronary artery disease in Asian Indians learnt and role of lippo protein. Indian Heart journal. 1996; 49: 25 -34. 17. Leech., psychological and Physiologic needs of patients with arterial occlusive disease during the Pre operative phase of hospitalization. Heart and Lung. 1991; 11 (5) : 447 -456.
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18. Montes., managing outpatient cardiac catheterization. American Journal of Nursing. 1997; 98 (7): 34 37. 19. Smith, Carolyn. Suitability of patient education material for cardiac catheterization. Clinical Nurse Specialist. 1998; 12 (4): 140 -145. 20. Winslow., the role of the Nurse In patient Education Focus: the cardiac Patient. Nurse and patient education. 2001; 1: 213 221. 21. Advocate health care, invasive procedure cardiac catheterization. http/www.Advocate health .com /heart care. 22. Angiography: patient preparation. http/www.germradiology.com / ang prep.htm. 23. Cardiac catherization procedure. http/ www.hg cardio .com / card cath .htm. 24. Abdellah , F.G., better patient care through nursing Research , New York : maxmillian Publishing Co., 1998. P .132-135. 25. Brunner, L. Suddarth , Text book medical surgical nursing , Philadelphia : Lippincott ., 1998 . P .356-368. 26. Burns, N. Practice of Nursing research Conduct, critique and utilization, Philadelphia: W.B. Saunders Co., 1993.

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SIGNATURE CANDIDATE

OF

THE

10 REMARKS OF THE GUIDE

11 11.1 NAME AND DESIGNATION Prof. K. RAMU OF GUIDE Principal, Shridevi Tumkur.

College

0f

Nursing.

11.2

SIGNATURE

11.3

CO-GUIDE

11.4

SIGNATURE

11.5 HEAD DEPARTMENT

OF

THE Prof. K. RAMU Principal & HOD dept. of MSN Shridevi College 0f Nursing. Tumkur.

11.6

SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL.

12.2 SIGNATURE

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