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CHAPTER- 1

INTRODUCTION

'' A HOSPITAL IS THE PLACE FOR CURE’’

BACKGROND OF THE STUDY—A nosocomial infection comes from Greek words


“NOSUS” meaning disease, “’KOMEION’’ meaning to take care of. A nosocomial
infection is also called as ‘’ hospital acquired infection. As infection acquired in
hospital by a patient who was admitted for a reason other than that infection .An
infection occurring in a patient in a hospital or other health care facility in whom the
infection was not present or incubating at the time of admission.

In 1861, Florence Nightingale observed the association of puerperal sepsis with the
attendants on patients by medical officers and students and she were successful to
bring a dramatic reduction in infection rate by the introduction of hand washing with
chlorinated line. After her experience of hospital acquired infection Florence
Nightingale [1883] wrote in her book notes on hospital infection. The very first’s
requirement in a hospital that it should to the sick no harm. The actual mortality in the
hospital, especially in those of large crowed cities, is very much higher than any
calculation founded or mortality of the same class of disease among student treated
outside hospital Lord Leisters [1867], introduced his antiseptic surgery with the
extensive use of carbonic acid.

Bacterial pathogens isolated from hospital environment are also known to develop
resistance to multiple antimicrobial agents. The emergence of multi-drug resistance
organism in hospital resulted in difficulty to treat nosocomial infection. Despite the
advance in modern medicine nosocomial infection still poses a risk of increased
morbidity and mortality to patients. For this, the hospital environment may play a
significant role. It is hereby, important to identify environment surfaces that are rich
in bacteria and have the potential to harbor pathogens. [Aschalew and Gelaw 2011]

Microbial contamination of hospital environment, especially in an operating theatre


has continued to increase prevalence of nosocomial infection, with resultant effect of
high morbidity and mortality rate among patient. [Singh et al, 2013]

Approximately 1.6 million Americans live in 16,000 nursing homes [NHs] across the
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nation , and 90 percent of those nursing homes residents are considered ‘frail
elderly’’. It is expected that the population of individuals residing in nursing homes
will increase in number and diversity in the coming years. It has been estimated that
between 1.6 and 3.8 million infection occurs in U.S. each year.

Healthcare associated infection are a major source of morbidity and mortality among
Nursing Superintendent residents and hospital acquired infection in nursing homes are
increasingly associated with multiple drug resistant organisms .Thus, prevention and
management of hospital acquired infection in nursing homes settings is vitally
important especially considering that 15 percent of U.S nursing home receive
deficiency citations for infection control each year. Some states have recently
regulated mandatory reporting of hospital-acquired infection in nursing homes or have
implemented state-wide learning collaborative; however, the effectiveness of this
initiative is not known.

In previous studies, our research group has examined relationships between infection
control structures and processes and hospital-acquired infection rates in elderly
Medicare patients admitted to intensive care units in hospitals. Additional studies
have been understand to examine the impact of mandatory public reporting of
hospital-acquired infection rates on infection control processes and hospital-acquired
infection rates in hospital and to estimate the costs attributable to those infections.

The build on previous work, this study prevention of nosocomial infection and cost-
effective in nursing homes, aimed to address gaps in current understanding of best
practices related to hospital-acquired infection prevention and the value of infection
control in nursing home settings.

NEED OF THE STUDY-

An infection acquired in the hospital that was not present at the time of hospital
admission. Hospital acquired infection add over 7.5 million it result in approximately
20,000 death and contribute to 60,000 more death yearly in the united states.[
Wilson et at 1991].

A recent multicenter European study demonstrated on overall hospital nosocomial


infection rate of 5 percent with the high-test rates in pedantries [23.5percent]

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hematology units [8.2percent] and neonatal units [7percent] and the lowest rates is
general pediatric units [1 percent]. A second prospective cohort study of 4684
pediatric patient found the highest nosocomial infection rates in children aged 2-3
million or younger [11.5 percent].

In India, however hospital often does not follow infection control practices and this
leads to the spread of disease. In response to the growing burden of hospital acquired
infection in India, GARP is issuing several key recommendations that aim at reducing
the prevalence of hospital acquired infection, including increased hand washing, use
of isolation room for infected patients, increased availability and uptake of diagnostic
test, reminder to limit catheter use and use of gloves and gowns. The Ministry of
health and family welfare task force also recommends that all hospitals create an
infection control plan, committee and team.

In Madhya Pradesh, the nosocomial infection rate is alarming and is estimated at


about 30-35% of all hospital admissions. Nosocomial infection typically affect
immune compraised patient due to factor like; age, underlying diseases, medical and
surgical treatments. Ageing of the population and increasingly aggressive medical and
therapeutic intervention, have created a plethora of vulnerable individuals.

Another important factor is the poor state of government hospital in India .The highest
infection rates are in intensive care unit patients. Nosocomial infection rate in adult
and pediatric ICUs are approximately three times highest than other hospital words.

Hence, we are conducting this research because when we were posted in Medical
hospitals, most of the students experienced that the people of fourth class workers
have inadequate knowledge regarding prevention of nosocomial infection. They have
more chance to develop nosocomial infection. They should have needs for education
regarding prevention and management of nosocomial infection.

PROBLEM STATEMENT –

“A study to assess the effectiveness of structured teaching programme on knowledge


regarding prevention of nosocomial infection among fourth class workers in selected
hospitals of Jabalpur (M.P)”.

3
OBJECTIVES –

 To assess the pre-test level of knowledge score regarding prevention of


nosocomial infection among fourth class workers.

 To assess the post-test level of knowledge score regarding prevention of


nosocomial infection among fourth class workers.

 To compare between pre-test and post-test level of knowledge score.

OPERATIONAL DEFINITION –

ASSESS- In this study assess refers to determine how much knowledge the fourth
class workers are having about prevention of nosocomial infection after structured
teaching programme.

EFFECTIVENESS- It refers to the extent to which the structured teaching


programme changed the level of knowledge of fourth class workers in hospital about
prevention of nosocomial infection.

STRUCTURED TEACHING PROGRAMME- It is a systematically developed


instructional method and teaching aid design following student to provide information
on prevention of nosocomial infection.

KNOWLEDGE- In this study, knowledge refers to the correct responses from the
fourth class workers regarding prevention of nosocomial infection as measured by
structured teaching programme.

NOSOCOMIAL INFECTION- It is an infection that is acquired in a hospital or


other care facility.

FOURTH CLASS WORKERS – Who are working in the hospital for cleaning
purpose; e.g.- peon, sweeper.

ASSUMPTION-

1. Fourth class workers may have inadequate knowledge regarding prevention of


nosocomial infection.

4
2 Structure teaching programme may enhance their knowledge level.

HYPOTHESIS –

H0-There will be no significant difference between knowledge pre and post test
knowledge scores..

H1-There will be significant difference between knowledge pre and post test
knowledge scores.

LIMLTATION----

1. Sample size is of 30.

2. Study is limited to fourth class workers.

3. Study is limited to the people who understand Hindi.

CONCEPTUAL FRAMEWORK-

According to Polit Hungler [1999], conceptual framework is cohesive and supportive


linkage of selected inter-related concepts. It serves as a guide to research and a spring
board for the generation of research hypothesis. Not every study is based a specified
conceptual framework. Conceptual model of this study is based on system model
[1985] a guide for development utilization and evaluation.

In present study input refers to the demographic variable such as age, education
of fourth class workers on prevention of nosocomial infection. Process refers to the
assessment of knowledge and to provide structured teaching programme on
prevention of nosocomial infection in selected hospitals of Jabalpur.

Output refers to the adequate knowledge of fourth class workers regarding


prevention of nosocomial infection that may lead to nosocomial infection that may
lead to increase in the knowledge of fourth class workers.

5
CONCEPTUAL FRAMEWORK BASED ON GENERAL SYSTEM MODEL

INPUT PROCESS OUTPUT

FOURTH CLASS ASSESS THE KNOWLEDGE OF


WORKERS FOURTH CLASS WORKERS GAIN
1. AGE REGARDING THE PREVENTION
OF NOSOCOMIAL INFECTION, KNOWEDGE
2. SEX
STRUCTURED TEACHING
3. EDUCATION
4. HABITS
PROGRAMME AND POST LACK OF
TEST.
5. OCCUPATION KNOWLEDGE

FEEDBACK

6
CHAPTER – 2
REVIEW OF LITERATURE

Review of literature is a key step in the research process. The term “Review of

literature” refers to an extension, exhaustive and systematic examination of


publication relevant to the research. One of the major functions of a literature review
is to ascertain what is already known in relation to a problem.

The review of literature of the present study was collected, organized and has been
presented under four sections:-

A. Literature related to Incidence and prevalence of nosocomial infection.

B. Literature related to knowledge of nosocomial infection.

C. Literature related to prevention of nosocomial infection.

D. Literature related to structured teaching programme on nosocomial infection.

A.] Literature related to Incidence and prevalence of nosocomial


infection –

A study was conducted by Ambannahowda [2010], to assess the prevalence of


nosocomial infection in the ICU. He selected total of 50 cases developing infection
after admission into intensive care unit and with detailed history, physical
examination and required lab investigations. Result showed statistically that among
50 patients who had nosocomial infections in the ICU, 28% had urinary tract
infection, 22% had lower respiratory infection 20% had so surgical site infection and
16% had soft tissue infection and 14% had pneumonias. Among 7 cases of pneumonia
5 were VAP. He concluded seen in intensive care unit.

A study was conducted by Jan Muhammad Shaik,Et al] [2008], an observational


study at tertiary care hospital, Pakistan on risk of acquiring infection in intensive care
unit they included 333 sample of above 16 years of age admitted in ICU more than 48
hours and observed result showed that out of 333 patients 97 patients had acquired

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nosocomial infection .The frequency of nosocomial infection was 29.12% .Hence,
they concluded that patients admitted in ICU are more risk for acquiring nosocomial
infection than others.

A study was conducted by Meena Agarwal,Et at [2003] to determine the incidence


of post operative nosocomial infection among neurological patients in post operative
period at AIMS. The random selection method is used to determine the incidence and
prevalence of nosocomial infection. They included 2441 neurosurgical post operative
patients of pre-operative infection, then analyzed for one year. After study result
showed 7.3% of patients have got post operative nosocomial infection.

B.] Literature related to knowledge of nosocomial infection---

A study was conducted by Humanakabirsickder [2010] to examine the nurse’s


knowledge and practice regarding provision of surgical site infection and to examine
the relationship between their knowledge and practice. The study was conducted from
November 2009 to January2010 at Shere-H-Bangla medical college and hospital. The
instrument of data collection was questionnaire which composed of three parts:
Demographic characteristics of subject, knowledge regarding prevention of surgical
site infection, questionnaire practice regarding that nurses reported a low level of
knowledge and high level of professional practice regarding prevention of surgical
site infection.

A study was conducted by Jonathan NA Quartey et al [2001] to determine and


compared the knowledge of nosocomial infection among clinical health care students
at the college of health science. University of Ghana. The study sample was drawn
from each academic program by a simple random sampling technique using the class
directory from each occurs. The infection control standard questionnaire was used to
assess the knowledge of students about their main domains i.e. hand hygiene
nosocomial infection and standard precautions results. Revealed that overall mean
percentage score of the participants on ICS was 6.54+2.58 with medical,
physiotherapy radiography and using standards recording mean percentage score of
70.58+0.62 , 65.02+2.00 , 64.74+1.19 and 61.31+2.35 respectively.

A study was conducted by Dr.Imad Fashafsheh and Mr.Ahmad Ayed [2000] to


assess the level of knowledge and practice of infection control among nurses in

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governmental hospitals of Palestine. A cross sectional study was conducted between
November, 2014 and January, 2015 in governmental hospitals found in North West
bank districts. Data were collected using pre tested questionnaire on 271 nurses
selected by purposive sample .Collected data were checked, coded and transferred to
SPSS version 20 for analysis. Frequency, Mean and other statistics were calculated-
value less than 0.06 were set as statistically significant. The current study revealed
that, approximately half (53.9%) of the studied sample had fair knowledge level
(>80%). However, the majority (91.1%) of the studied sample had good practice
(88%). No significant statistical differences were found between mean knowledge
scores toward age, years of experience, and training course (=2.263,1.607,0.210)
respectively at p < 0.05(0.082,0.188,0.647) respectively.

C.] Literature related to prevention of nosocomial infection---

A study was conducted by Sureshchandra Yadav et, al [2012], to identify the need for
using prophylactic antibiotic in clean-contaminated surgeries, to identify the
prevalence of organisms in patients who are not given prophylactic. Antibiotic and to
study whether presence of risk factor increase the incidence of surgical site infection.
They collected 100 cases admitted under two groups of 50 each. Group A were given
prophylactic antibiotic and Group B were not given any such antibiotic and all
surgeries other than clean and clean-contaminated surgical cases where excluded from
the study. They got results out of 50 patients in group B who were not given
prophylactic antibiotic ,6 patients had more than one risk factor for development of
SSI[surgical site infection] and both of then developed SSI[surgical site
infection].Group A had 35 clean, out of which none of them were infected.

A study was conducted by Kibret M et, al [2010], a cross-sectional study on


antibiogram of nosocomial urinary tract infection at ethiopia.T hey selected 1254
patients for a year. Their antimicrobial susceptibility tests were done using disc
diffusion technique as per the standard of Kirby-bauer method and they got result as
out of the 1254 patients,118 [9.4%] developed nosocomial UTI [ urinary tract
infection ].Thus, they have concluded that catheterization and pre-operative antibiotic
prophylaxis were found to be risk factor for nosocomial infection.

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A study was conducted by M.Pagani N, Di Peeri G, [2009] the aim of study is to
review barriers to nursing adherence to no pharmacological evidence-based guidelines
for preventing ventilator-associated pneumonia. Descriptive study design was used
and the setting is intensive care units.110 nurses approached at two critical care
nursing meeting: A questionnaire was administered to nurses. The study concluded
nurses had different levels of adherence than physicians for many non-pharmacologic
strategies .The most important barriers to implementation were environment-related
and other reasons for non-adherence show significant variability between nurse and
physician opinion leaders, patient-related barriers being significantly more important
for nurse. This study helped the researcher to develop the tool for current study.

D.] Literature related to structured teaching programmed on


prevention of nosocomial infection--

A study was conducted by Krishna Chauhan [2011] to assess the effectiveness


of structured teaching programme on knowledge regarding prevention of nosocomial
infection among the staff nurses working in selected areas of Indira Gandhi medical
college and hospital, Shimla-Himachal Pradesh .Quantitative research approach and a
pre-experimental research design was adopted for the study.50 staff nurses were
selected by using convenient sampling technique. The findings of the study showed
that mean post-test knowledge score (37.30) was higher than the pre-test knowledge
score (32.32). Hence, the structured teaching programme given to the staff nurses was
effective. Calculated t-value was 5.61 and table value was 2.01 at 0.05 level of
significance .It showed that the calculated t-value was greater than tabulated value.

A study was conducted by Antony Rose A. by [2008] to assess the effectiveness


of structured teaching program on knowledge regarding prevention of nosocomial
infection in newborns among the staff nurses working in pediatric and labor units of
selected hospitals in Tumkur District. The author conducted a research on neonatal
nosocomial infection followed by a quasi-experimental study among 60 staff nurses
and thoroughly scrutinized the effectiveness of structured teaching programme
regarding knowledge on nosocomial infection in newborns. The study also assessed
the level of knowledge regarding nosocomial infection in newborns among staff
nurses and determined the association between pre-test knowledge score on
nosocomial infection in newborns with selected baseline characteristics. Analysis was

10
made using various tolls like frequency and percentage, mean, standard deviation,
paired “t” test, and chi-square test. The result showed that there is a significant
difference with a (paired) “t” value of 23.413 at (p<0.001) levels and it reveals a
significant gain in knowledge among staff nurses following the structured teaching
programme on nosocomial infection in newborns.

A study was conducted by Rajini and Vasantha Kalyani [2006] to assess the
effectiveness of structured teaching programme on level of knowledge regarding
infection control practices among staff nurses working in critical care units. The
conceptual framework for the study was based on king`s goal attainment theory. The
research approach adopted for the study was quantitative approach. Purposive
sampling was done and 60 staff nurses working in ICU were selected for the study. A
self administered questionnaire was developed as a tool for data collection .The
questionnaire consisted to two section. Section 1 of the tool had demographic item,
section 2 had knowledge about infection control practices. Analysis of data was done
by using descriptive statistics. The following are some of the salient findings of the
study. Mean and standard deviation were used to calculated the knowledge with the
selected variables. The overall pre-test and post-test mean knowledge was found to be
31.46 and 43.56% respectively indicating the enhancement knowledge as 12% paired
“t” test shows statistical significance at 5% level (p 0.05 ) shows there is a strong
association between the pre-test and post-test level of knowledge of experimental
group the establishing the impact of structured teaching programme on infection
control practices among staff nurses.

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CHAPTER 3

RESEARCH METHODOLOGY

This chapter deals with the methodology adopted for assessing the knowledge of
fourth class workers .It includes the description of research approach, research design,
setting of the study, sample and sampling technique, development of data collection
tools and questionnaire, procedure for data collection and the plan for data analysis.

Further the study is aimed at determining the effectiveness of structured


teaching programme on knowledge and also to associate demographic variable like
age, education, occupation, religion, type of family, monthly income etc.

Research Approach: -

Research approach is a systematic, objective method of discovery with


empirical evidence and rigorous control. The control is achieved by holding
conditions constant and varying only the phenomenon under study.

The investigator employed quantitative evaluative approach to determine the


effectiveness of structured teaching programme regarding prevention of nosocomial
infection among fourth class workers.

Research Design: -

The research design for present study is pre experimental. One group pre-test
and post-test design to measures the effectiveness of the structure teaching
programme for fourth class workers of selected hospital of Jabalpur.

Variable: -

A variable is a measurable component of an object or event that may fluctuate


in quantity or quality from one individual, objects or event to another individual of the
same general class.

 Independent : -

Structure teaching programme on prevention of nosocomial infection among


fourth class workers in selected hospital.
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 Dependent Variable : -

Knowledge of fourth class workers regarding on prevention of nosocomial


infection.

Setting of the study: -

The study will be conducted in City hospital and cancer center Jabalpur.

Population : -

The population of the present study is fourth class workers of City hospital and
cancer center Jabalpur.

Sample Size & Sampling Technique: -

A sample is used in research because it is not feasible to study the whole


population from which it is drawn. The process of sample makes it possible to accept
a generalization to the intended population based on careful observation of variable
within a relatively small proportion of population.

In present study the sample are fourth class workers of hospital. Sample size for
the study was 30 which fulfill the sampling criteria.

Criteria for Sample selection: -

In sampling criteria the researcher specifies the characteristics of the


population under the study by detailing the inclusion and exclusion criteria.

Inclusion Criteria: -

 People who are working in Hospital.

 People who are able to speak, read and write Hindi language.

Exclusion Criteria: -

 The people who cannot read and write Hindi.

 The people who are not willing to participate in study.

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Data Collection:-

Socio-Demographic variables and structured knowledge questionnaire was


used to collect data from fourth class workers of hospital.

Development of Tools:-

Data collection and test are the procedure of analysis used by researcher to
observe or measure the key variable in the research problem. The present study aimed
to evaluate the effectiveness of structured teaching programme on knowledge
regarding prevention of nosocomial infection. Questionnaire was developed on
existing knowledge regarding nosocomial infection was used as tool for data
collection. The questionnaire was divided in two sections where section A consists 5
items of demographic data of the subjects and Section B consists of 30 items
pertaining to the existing knowledge on nosocomial infections. Every question of
section B has only one right answer and 1 point was considered as the obtained score
for the item.

Scoring: Further the obtained data was further categorized into three categories
namely Inadequate, Moderate and Adequate level of knowledge. The distribution was
done as follows;

1. Inadequate : Below 50% of the total score

2. Moderate : 50% - 75% of the total score

3. Adequate : Above 75% of the total score

Validity of Structured teaching programme :-

To establish criteria based validity instrument was administer in fourth class


workers of hospital .It was found that instrument was tapping the area of knowledge
successfully of which it was structured.
The tools and methods used for collecting the data to measure the variables of the
study consist of questions related to demographic data of consist of standardized
questions to assess the knowledge of nosocomial infection. It consists of 30 items
describing the nosocomial infection. Content validity of the questionnaires was
consulted with experts and guides Mrs. Mousami Lendhe Mam, Mrs. Tuleshori

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Mam, Miss. Ranjana Mam, Mrs. Pratibha Mam, Miss. Nikita Mam, Mrs. Subha
Yadav from nursing and other various related fields.

Reliability of the tool :-

Reliability is defined as the extent to which the instrument yield the same result
on repeated measures. It is then concerned on with consistency, accuracy, stability
and homogeneity. (Wood JB, Harber.1999 )

After establishing the validity of the tool be used for study, the final tool was made
and then the reliability of the tool was done. The tool was tested for reliability on 3
responded.

Pilot Study:-

A pilot study is small preliminary investigation of the same general characteristic


as the main study as the major study which is designed to acquaint the researcher with
problem that can collect in preparation for a large research study.( treece and treece,
1986)

The pilot study was conducted on 16.12.2017 to 22.12.2017 to assess the


feasibility of the study and to decide data analysis. Administrative permission was
granted formally by the authority of the Suvidha Hospital the pilot study was
conducted on 3 people.

Data was analyzed by statistical test. The pilot study did not show any major changes
in the design of questionnaire and the structured teaching programme developed by
the researchers

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Research Approach
. (Quantative Evaluative approach

TARGET POPULATION (fourth CLASS WORKERS OF CITY


HOSPITAL)

ACCESSIBLE POPULATION ( 4THCLASS WORKERS OF


CITY HOSPITAL)

9
SAMPLING TECHNIQUE
(CONVENIENT9)TECHNIQUE)

TOOL FOR DATA COLLECTION (SELF STRUCTURED QUESTIONNAIRE FOR ASSESSING THE
KNOWLEDGE OF FOURTH
99 CLASS WORKERS)

PRE-TEST

INTERVENTION OF STRUCTURED TEACHING


PROGRAMME

POST-TEST

DATA ANALYSIS AND INTERPRETATION

REPORTING

FINDINGS

FIGURE 2. SCHEMATIC REPRESENTATION


16 OF RESEARCH
DESIGN
Procedure for Data Collection :-

The formal permission was obtained from the authority of City Hospital Jabalpur
thereafter study was conducted from 6.12.2017 to 12.12.2017. 30 fourth class
workers were considered as the Sample of the study.

The following schedule was followed for data collection. After identifying the
sample, objective were discussed and consent participation in the study was taken
from the selected group. The investigator assures the subject about the confidentiality
of the data. The investigator herself administered the structured questionnaire for the
pre-test. The duration of data collection for each sample was 15 to 20 min. The
structured teaching programme on knowledge regarding prevention of nosocomial
infection among fourth class workers of hospital was disseminated to the
experimental group after the pre-test and brief introduction.

The instruction on the post-test was given to the respective participants. Time taken
for post –test by each sample was approximately 15 min. After the participation all
participation were thanked for their participation in the study.

Plan for Data Analysis :-

Data analysis is a systematic organization synthesis data and the testing of hypothesis.
(Polit and Hungle).

Socio demographic data would be analyzed using descriptive statics that is frequency
and percentage, Mean and standard deviation of pre-test and post-test knowledge
score were calculated .Computing “t” value to find out significant of difference
between the mean pre-test and post-test knowledge score.

Ethical consideration:-

The research committee has approved the research problem and objectives starts for
the present study. Informed consent was obtained from the promissory authority of
the region. Explanation was given regarding the purpose of study. Confidentiality was
ensured. Permission from the higher authorities were obtained. Any individual
participant has the right to leave from the study at any time without assigning any
region there to the investigator.

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Summary:-

This chapter deals with research methodology which includes design, setting of the
study. Population, sample and sampling technique, sample selection criteria, validity
and reliability of tool, pilot study and procedure and plan of data analysis.

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CHAPTER -4
DATA ANALYSIS AND INTERPRETATION

This chapter deals with the organization and analysis of the data and its interpretation.
The data collected was analyzed as per the objectives of the study. The purposed of
analysis is to reduce the data into meaningful and interpretable so that research
problem can be studies and tested.
As Kerlinger (1972) stated analysis if categorizing, manipulating and summarizing
the data to obtain research problem interpretation of tabulated data can bring rights to
the real meaning of the finding of the study.

Polit and Hungler (1999) described analysis as a a process of organizing and


synthesizing data in such a way that research question can be answered and
hypothesis based.

Interpretation refers to the process sense of research and of examining the implication
the finding within the broad context.

Abdulla and Cavine (1970) interpretation of tabulated data can brief light to the real
meaning of the study.

In this study analysis and interpretation of data were based on data collected from
fourth class workers of Jabalpur Hospital and Research Centre.

Both descriptive and inferential statistics have been used. Analysis and interpretation
of data of the study and hypothesis to tested.

PROBLEM STATEMENT –

“A study to assess the effectiveness of structured teaching programme on knowledge


regarding prevention of nosocomial infection among fourth class workers in selected
hospitals of Jabalpur (M.P)”

19
OBJECTIVE

 To assess the pre-test level of knowledge score regarding prevention of


nosocomial infection among fourth class workers.

 To assess the post-test level of knowledge score regarding prevention of


nosocomial infection among fourth class workers.

 To compare pre-test and post-test level of knowledge score on nosocomial


infection among fourth class workers.

Hypothesis

H0-There will be no significant between pre-test and post-test knowledge score among
fourth class workers.

H1-There will be significant between pre-test and post-test knowledge score among
fourth class workers.

Organization of the study findings

In order to find out the effectiveness of structured teaching programme the data were
tabulated analyzed and interpreted using descriptive and inferential statistics methods.
The data were presented under the following heading.

Section I : Distribution of fourth class workers according for demographic variables


using frequency and percentage.

Section II : Assessment of the pretest knowledge score regarding prevention of


nosocomial infection among fourth class workers of Jabalpur Hospital and Research
Centre.

Section III : Assessment of the post test knowledge score regarding prevention of
nosocomial infection among fourth class workers of Jabalpur Hospital and Research
Centre.

Section IV : Comparison of pre and post test knowledge scores regarding prevention
of nosocomial infection among fourth class workers of Jabalpur Hospital and
Research Centre.

20
Master Demographic Characteristic
Table No. 1

Demographic
Frequency Percentage
Variables Criteria
20-30 Years 11 36.67
31-40 Years 13 43.33
Age
41-50 Years 4 13.33
More than 50 Years 2 6.67
Female 17 56.67
Gender
Male 13 43.33
10th 19 63.33
12th 11 36.67
Education
Graduate 0 0.00
Illiterate 0 0.00
Rs.2500 - Rs. 5000 7 23.33
Rs.5001 - Rs. 7000 16 53.33
Monthly Income
Rs.7001- Rs. 10000 7 23.33
More than R. 10000/- 0 0.00
Family / Relatives 2 6.67
Source of Friends 6 20.00
Knowledge New Paper / TV 7 23.33
Health Workers 15 50.00

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Table 2. Distribution of sample according to their age.

N=30
Age Frequency Percentage

20-30 Years 11 36.67

31-40 Years 13 43.33

41-50 Years 4 13.33

More than 50 Years 2 6.67

Total 30 100

Data depicted in table no. 2 shows the distribution of subjects according to their age.

Figures revealed that most of the subjects 13 (43.33%) were aged 31-40 years in age,

11(36.67%) age ranged between 20-30 years, 4(13.33%) age range was 41-50 years

and only 2(6.67%) subjects age was more than 50 years.

22
Fig : 3 Distribution of sample according to their age

14
13

12
11

10

4
4

2
2

0
20-30 Years 31-40 Years 41-50 Years More than 50 Years
Age

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Table 3. Distribution of sample according to their gender.

N=30
Gender Frequency Percentage

Female 17 56.67

Male 13 43.33

Total 60 200

Above statistics shows the gender distribution of the subjects and 17(56.67$) subjects
were female and rest 13 43.33%) were male.

24
Fig.4 Distribution of sample according to their gender.

18
17

16

14
13

12

10

0
Female Male
Gender

25
Table 4. Distribution of sample according to their education.

N=30
Education Frequency Percentage

10 TH 19 63.33

12 TH 11 36.67

Graduate 0 0.00

Illiterate 0 0.00

Total 30 100

Data in above table revealed that 19(63.33%) subjects educational qualification was
10th standard while rest 11 (36.67%) were educated till 12th standard

26
Fig 5. Distribution of sample according to their education.

20
19

18

16

14

12
11

10

0 0
0
10 TH 12 TH Graduate Illiterate
Education

27
Table 4. Distribution of sample according to their income.
N=30
Monthly Income Frequency Percentage

Rs.2500 - Rs. 5000 7 23.33

Rs.5001 - Rs. 7000 16 53.33

Rs.7001- Rs. 10000 7 23.33

More than R. 10000/- 0 0.00

Total 30 100

Above tabulation shows the distribution of subject according to their income and data
revealed that more than half 16 (53.33%) , 7 (23.33%) monthly income was 2500-
5000 and 7001-10000 per month.

28
Fig 6. Distribution of sample according to their income.

18

16
16

14

12

10

8
7 7

0
0
Rs.2500 - Rs. 5000 Rs.5001 - Rs. 7000 Rs.7001- Rs. 10000 More than R. 10000/-
Monthly Income

29
Table 6. Distribution of sample according to the existing knowledge regarding
prevention of nosocomial infection.

N=30
Source of Knowledge Frequency Percentage

Family / Relatives 2 6.67

Friends 6 20.00

New Paper / TV 7 23.33

Health Workers 15 50.00

Total 30 100

Data depicted in above table showed the distribution of subjects according to their
pervious knowledge and 15 (50.00%) subjects had gained knowledge on prevention of
nosocomial infection from health workers, 7(23.33%) gained knowledge from news
paper/TV, 6 (20.00%) gained knowledge from their friends and 2 (6.67%) knows
about it through their family and relatives.

30
Fig 7. Distribution of sample according to the existing
knowledge regarding prevention of nosocomial infections.

16
15

14

12

10

8
7
6
6

2
2

0
Family / Relatives Friends New Paper / TV Health Workers
Source of Knowledge

31
Table-7 Assessment of Pre test knowledge score

N=30
Level Of Knowledge Count Percent

30 100%
Inadequate

0 0%
Moderate

0 0%
Adequate

Data depicted in above graphical presentation shows score on level of knowledge


regarding nosocomial infections among fourth class workers of City Hospital Jabalpur
and data revealed that 100% subjects knowledge was at inadequate level before
administering STP.

Table 8: Mean, SD and Mean% of the Pre-test knowledge on nosocomial


infections-

Knowledge Level Mean SD Mean %


Over All 10.93 1.63 36.44%

Table 8 showed that over all pretest mean score is 10.93 SD 1.63 and mean
percentage is 36.44%

32
Fig 8. Assessment of Pre test knowledge score

Percent
120%

100%
100%

80%

60%

40%

20%

0% 0%
0%
Inadequate Moderate Adequate

33
Table-9 Assessment of Post test knowledge score

N=30
Level Of Knowledge Count Percent
0 0%
Inadequate
21 70%
Moderate
9 30%
Adequate

Data depicted in above graphical presentation shows score on level of knowledge


regarding nosocomial infections among fourth class workers of City Hospital Jabalpur
and data revealed that 70% subjects knowledge was moderate and 30% of the subjects
gained adequate level of knowledge after administering STP.

Table 10: Mean, SD and Mean% of the Post-test knowledge on nosocomial


infections-

Knowledge Level Mean SD Mean %


Over All 21.73 1.36 72.44%

Table 10 showed that over all post-test mean score is 21.73 and SD 1.36 and mean
percentage is 72.44%

34
Fig 9. Assessment of Post- test knowledge score

0.8

70%
0.7

0.6

0.5

0.4

30%
0.3

0.2

0.1

0
0
Inadequate Moderate Adequate

35
Table-11 Comparison of Knowledge Scores between Pre-test and Post-test mean
scores

N=30
Mean t'
Pre Test Post Test p Value
Diff. Value

Mean SD Mean SD
10.8 28.51 0.0000
10.93 1.64 21.73 1.36

The data analyzed in above table 11, on obtained pre test and post test means score in
context to assess the knowledge on nosocomial infections among fourth class workers
of city hospital Jabalpur. Obtained knowledge score of pre test had mean value 10.93
and SD 1.64 whereas post test mean value is 21.73 and SD 1.36. To compare the pre
and post test mean scores paired ‘t’ test was computed and the results indicated
significant difference among the group as the obtained ‘t’ value 28.51 (df=29) was
much higher than the required level of significance therefore null hypothesis was
rejected.

36
Fig 11. Comparison of Knowledge Scores between Pre-test
and Post-test mean scores

25

21.73

20

15

10.93

10

1.64 1.36

0
Mean SD Mean SD
Pre Test Post Test

37
CHAPTER V
DISCUSSION, SUMMARY, CONCLUSION IMPLICATION,
NURSING, EDUCATION, NURSING ADMINISTRATION,
NURSING RESEARCH AND RECOMMENDATION.

The present study aims to assess the knowledge level of fourth class workers of
Selected hospital regarding Prevention of Nosocomial Infection. The study was
conducted in Jabalpur Hospital and Research Centre. A structured questionnaire was
selected on the basis of the objective of the study, was considered to be the most
appropriate instrument for assessing the level of knowledge regarding prevention of
nosocomial infections, convenient techniques was used to select 30 fourth class
workers.

This chapter deals with finding of the study to assess the effectiveness of structured
teaching programme on knowledge regarding prevention of nosocomial infections
among fourth class workers in selected hospitals of Jabalpur.

Section I :-

Distribution of fourth class workers according for demographic variables using


frequency and percentage.

Section II :-

Assessment of the pretest knowledge score regarding prevention of nosocomial


infection among fourth class workers of Jabalpur Hospital and Research Centre.

Section III :-

Assessment of the post test knowledge score regarding prevention of nosocomial


infection among fourth class workers of Jabalpur Hospital and Research Centre.

Section IV :-

Comparison of pre and post test knowledge scores regarding prevention of


nosocomial infection among fourth class workers of Jabalpur Hospital and Research
Centre.

38
MAJOR FINDINGS
Section - I : Finding related to demographic characteristic of the sample

Data revealed that 13 (43.33%) subjects were aged 31-40 years in age, 11(36.67%)
age ranged between 20-30 years, 4(13.33%) age range was 41-50 years and only
2(6.67%) subjects age was more than 50 years.

Statistics showed the gender distribution of the subjects and 17(56.67$) subjects were
female and rest 13 43.33%) were male.

19(63.33%) subjects educational qualification was 10th standard while rest 11


(36.67%) were educated till 12th standard.

(53.33%) , 7 (23.33%) monthly income was 2500-5000 and 7001-10000 per month.

Findings regarding pervious knowledge revealed that 15 (50.00%) subjects had


gained knowledge about prevention of nosocomial infection from health workers,
7(23.33%) gained knowledge from news paper/TV, 6 (20.00%) gained knowledge
from their friends and 2 (6.67%) knows about it through their family and relatives

Section – II : Finding related to the pre-test level of knowledge.

Finding on score of pre-test on level of knowledge regarding nosocomial infections


among fourth class workers of City Hospital Jabalpur and data revealed that 100%
subjects knowledge was inadequate before administering STP

Section – III : Finding related to the post test level of knowledge

Data revealed that 70% subjects knowledge was moderate and 30% of the subjects
gained adequate level of knowledge after administering STP.

Section – IV : Finding related to comparison of pre-post test level of knowledge

To compare the pre and post test mean scores paired ‘t’ test was computed
and the results indicated significant difference among the group as the obtained ‘t’
value was much higher than the required table value.

39
CONCLUSIONS

After the detailed analysis, this study leads to the following conclusion: Data
presented table 1-7 shows health workers increased knowledge regarding nosocomial
infection. After the implementation of Structured Teaching Programme (STP), there is
a significant increase in knowledge which is calculated by paired t-test and the result
was 28.51 (2,29 df). Hence researcher came with the final conclusion that structural
teaching program is an effective tool to educate the society in concern with the
knowledge regarding nosocomial infections.

RECOMMENDATIONS

 The Present study was conducted taking small sample size, a more extensive
study on large sample is recommended for wider generalization.
 A experimental study can be conducted with control group for comparison
 A similar study can be conducted in hospital settings
 To increase awareness health information can be passed out to others by
various sources like: Voluntary organization, Government services, Private
health camps, Nursing personnel and other health professionals with the help
of mass media.

NURSING IMPLICATION:- Good health depends upon the safe environment.


attainment of good health is important for everyone. The fourth Class workers of
hospital should seek knowledge regarding prevention of nosocomial infection.
The pre-test study finding have implication for nursing practice, nursing
education, nursing administration ,nursing research and community education.

NURSING PRACTICE :- The nurse education need the prepare self learning
material such as learning packages and video films, poster, charts which can be placed
in schemes library. As a nurse practitioner the nurse can out reach their service to
individual about prevention of nosocomial infection.
It was found in the study that fourth Class workers have poor knowledge
regarding prevention of nosocomial infection that an implementation of structured
teaching programme to increase the level of knowledge and help to minimize the false
practices.

40
NURSING EDUCATION :- Education enables practitioners to share and
disseminate evidence that demonstrates the actual practice of reduce as it is
experienced in the realities.

NURSING ADMINISTRATION :- Nurses play a pivotal role in preventing hospital


-acquired infection, not only by ensuring that all aspects of their nursing practice is
evidence based, but also through nursing research and patient education.
As patient advocates, nurses are in the unique position to affect change to
improve patient care standards.

41
BIBLIOGRAPHY

1. Adams D, Elliot TS. Skin antiseptics used prior to intravascular catheter


insertion. British Journal of Nursing. 2007;16(5):278–280.
2. Balamongkhon B, Thamlikitkul V. Implementation of chlorhexidine gluconate
for central venous catheter site care at Siriraj Hospital, Bangkok,
Thailand. American Journal of Infection Control. 2007;35(9):585–588.
3. Department of Health. Saving Lives: reducing infection, delivering clean and
safe care. 2007. Available from: http://www.dh.gov.uk
/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance
/DH_078134.
4. Department of Health. NHS reference costs 2009–10. 2011. Available
from:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications
/PublicationsPolicyAndGuidance/DH_123459.
5. White,L (2005): Foundation of Basic Nursing 2nd Thomson UAS p-357.
6. Taylor,C: and Lemon,P(2001): Fundamental of Nursing the Art & Science of
Nursing care fourthEd Lippincott Philadolphia,pp 536-560.
7. Shweta, G,March,(2002)Nursing Journal of India Role of Infection control
nurse in surveillance of Nosocomial Infection.
8. Smeltzer,S,& Bare ,B(1997):Brunner and Suddaraths Textbook of Medidal
Surgical Nursing 9th ed Lippineott company,Philadalphia pp – 1116-1120
9. Perry,A. & Potter,P.,Fundamentals of nursing fourth ed C.U. Mosby co st.
Louis.Battimore,pp-742-755.
10. Paul Challinor,John sedge wick et al (1998) “Principles and practice of
nursing”Stanley thrones publishers pp-185-188.
11. John T.Daugirdas,Peter Gerard Blake et al (2007) “Handbook of Medical
Surgical Nursing”fourthEdition Lippincott Williams & wikins publishers pp-
542-548.
12. Chadwick, P.R., Beards, G., Brown, B., et al. (2000) Management of hospital
outbreaks due to small round structured viruses. Journal of Hospital Infection,
45 (1), 1-10. Available at:
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947408355 Cross
Ref link Pubmed link

42
13. Crabtree, A.& Henry, B.(2011) Non-pharmaceutical Measures to prevent
Influenza Transmission: The Evidence for Individual Protective Measures.
Winnipeg, Canada: National Collaborating Center for Infectious Disease.
14. Damani, N.N. (2011) Basic concepts. In: Damani, N.N. Manual of Infection
prevention and Control, 3rd edn. Cambridge: University Press. Cross Ref link.

43
Annexure I

Permission Letter of main Study

44
Annexure II

Letter Permission of Pilot study

45
ANNEXURE – III

46
ANNEXURE – IV

CERTIFICATION OF VALIDATION

This is to certified as the tool constructed by Miss Deeksha Patel, Miss


Deepa Sonwani, Mr.Deepchand Thakur, Miss Divya Singh, Miss Hepsiba Rai B.Sc.
Nursing IV Year Students of Nandvandan College of Nursing Jabalpur, used in their
study to assess the effectiveness of “A Study To Assess The Effectiveness Of
Structured Teaching Programme On Knowledge Regarding Prevention Of
Nosocomial Infection Among Fourth Class Workers In A Selected Hospital Of
Jabalpur (M.P.)” have been found valid by me.

SIGNATURE:

NAME: DESIGNATION SIGNATURE

MRS.MOUSAMI LENDHE MAM Principal ______________

MRS.TULESHORI MAM Lecturer ______________

MISS RANJANA MAM, Lecturer ______________

MRS. PRATIBHA MAM Lecturer ______________

MISS NIKITA MAM. Lecturer ______________

MRS. SUDHA YADAV Lecturer ______________

SUGGESTIONS: ____________________________________________________

_____________________________________________________________________

DATE:

PLACE : Nandvandan College of Nursing ,Jabalpur.

47
ANNEXURE – V

Tools
SECTION--A
Socio demographic Variables
INTRODUCTION- In this section, some information are given please read carefully
and tick the most appropriate in the [ ] your answer will be kept confidential.

Code No. :

1.] AGE:-
a.] 20-30 years ( )
b.] 31-40 years ( )
C.]41-50 years
( )
d.] above the 50 years
( )
2. GENDER: -
a.] Male ( )
b.] Female ( )
3.] EDUCATION: -
( )
a.] High school ( )
( )
b.] Higher secondary ( )
c.] Graduate ( )
d.] Illiterate
( )
4.] INCOME: -
( )
a.] 2500 - 5000
( )
b.] 5001 - 7000
c.] 7001 - 9000 ( )

d.] More than 10,000 ( )

48
5.] Previous knowledge regarding nosocomial infection: -
a.] Family / Relative ( )

b.] Friends ( )
c.] Mass media ( )
d.] Health professionals
( )

49
SECTION - B
Knowledge Questionnaire
1.] Nosocomial infection is -
a.] Home-acquired infection ( )
b.] Industrial-acquired infection
( )
c.] Hospital-acquired infection
( )
d.] Agriculture-acquired infection
( )
2.] Good health depends upon the-
a.] Safe environment ( )
b.] Infectious food ( )
c.] Infectious water
( )
d.] All of above
( )
3.] Factors influencing the nosocomial infection are-
a.] Patient susceptive ability ( )

b.] Microbial agent ( )

c.] Environment factor ( )


d.] All of the above ( )
4.]............................. Are more susceptible to have hospital-acquired infection -
( )
a.] Doctors
b.] Nurses ( )

c.] Visitors ( )

d.] Fourth class workers ( )

5.] The main respiratory disease causes by nosocomial infection - ( )


a.] Pneumonia ( )
b.] T.B.
( )
c.] Jaundice
( )
d.] Diarrhea

50
6.] the most common hospital-acquired infection seen in hospital is---
( )
a.] Urinary tract infection
( )
b.] Gastrointestinal infection
c.] Respiratory infection ( )

d.] Skin infection ( )

7.] Person have more chances to develop nosocomial infection while -


a.] low immunity power
( )
b.] Empty stomach
( )
c.] Low blood level
( )
d.] All of above
( )

8.] Infection can be spread while -


( )
a.] Eating
( )
b.] laughing
( )
c.] Sneezing
( )
d.] Infected hand

9.] In the following is an example of direct contact transmission -


a.] Drinking contaminated water ( )

b.] Coughing or sneezing ( )


c.] A bite from an insect ( )
d.] Shaking hand
( )

51
10.] In the following is an example of droplet transmission -
( )
a.] Laughing
( )
b.] Infected hand
( )
c.] Sneezing
( )
d.] Eating
11.] In the following is an example of vector borne transmission - ( )
a.] Contaminated food ( )
b.] Contaminated water
( )
c.] A bite from an insect
( )
d.] all of the above
12.] Sign and symptoms of nosocomial infection are --- ( )
a.] jaundice, convulsion ( )
b.] cough, fever, running nose
( )
c.] Fatigue, weight loss
( )
d.] Hair loss, backache
13.] Nosocomial infection can be detect by--
( )
a.] Blood test or urine examination
( )
b.] Blood pressure examination or abdominal examination
( )
c.] Mental examination
d.] X--ray ( )

14.] If hospital-acquired infection is occurs the person must----


( )
a.] Contact with doctor
b.] Take home remedies ( )

c.] Try black magic ( )


d.] None of these ( )

52
15.] Single most effective method to prevent Hospital acquired infection is--
( )
a.] Educating health worker
( )
b.] Hand washing properly
( )
c.] Wearing gown
( )
d.] Bathing
16.] Hand washing will be perform-- ( )
a.] Before doing any work
( )
b.] Before and after doing any work
( )
c.] After doing any work
( )
d.] After touching patients
17.] In the following---------can be reused--
a.] Dusting water ( )

b.] Mask ( )
c.] Gloves ( )
d.] Gown
( )

18.] Hand washing should be perform with--- ( )


a.] Plain water
( )
b.] Running
( )
c.] Plain soap
( )
d.] Antiseptic solution
19.] There are ..........step of hand washing -----

a.] 10 Steps ( )

b.] 7 steps ( )

c.] 8 steps ( )
d.] 6 steps ( )

53
20.] In time of hand washing we must rubbed our hand for--- ( )
a.] 1 Minute ( )
b.] 15 Second
( )
c.] 20 Second
( )
d.] 45 Second
21.] The correct order to remove personal protective equipment are----- ( )

a.] Apron, Gloves, Mask ( )

b.] Mask, Apron, Gloves ( )


c.] Gloves, Apron, Mask ( )
d.] Gloves, mask, Apron

( )
22.] The greatest drawback to the routine use of antibacterial hand soaps is that they--
- ( )

a.]They are Expensive ( )


b.] Irritate the skin ( )
c.] Irritate the eye
d.] All of above

23.] The correct order for putting the personal protective equipment is----
( )
a.] Gown, Mask, Gloves, Eyewear
( )
b.] Mask, Gloves, Gown, Gloves
( )
c.] Mask, Eyewear, gown, gloves
( )
d.] Eyewear, Gloves, Gown, Mask

24.] There are................. Colors of buckets in--- ( )


a.] Two ( )
b.] Six
( )
c.] Three
( )
d.] Five

54
25.] Colures of Bio-medical waste buckets are---
( )
a.] Red, Blue, Yellow, Black
( )
b.] Pink, Violet, Grey, White
( )
c.] Green, Purple, Brown, Pink
( )
26.] Sharp objects must be discarded in---
a.] Red Bucket ( )

b.] Yellow Bucket ( )


c.] Blue Bucket ( )
d.] Black Bucket
( )
27.] Anatomic waste should be discarded in----
( )
a.] White Bucket
( )
b.] Red Bucket
c.] Yellow Bucket ( )

d.] Black Bucket ( )

28.] Non-infectious waste should be discarded in ----


( )
a.] Black Bucket
b.] Red Bucket ( )

c.] Yellow Bucket ( )

d.] Black Bucket ( )


29.] ...........................Should be put in red bucket--
( )
a.] Domestic waste
( )
b.] Sharp object
( )
c.] Plastic waste
d.] Liquid ( )

30 .......................Should be put in white bucket----


a.] Needles ( )

b.] Domestic waste ( )


c.] Papers ( )

d.] Sharp object ( )

55
ANNEXURE – VI

ANSWER KEY

QUESTION ANSWER

1 C
2 A
3 D
4 D
5 B
6 B
7 A
8 D
9 D
10 C
11 B
12 B
13 A
14 A
15 B
16 B
17 A
18 D
19 B
20 C
21 C
22 C
23 B
24 D
25 A
26 B
27 B
28 B
29 C
30 A

56
ANNEXURE – VII
Questionnaire (Hindi)

Questionnaire
[k.M ¼v½
bl Hkkx esa vkidksa dqN tkudkfj;kW nh xbZ gSA uhps fn;s x;s
iz’ukss esa ls lgh ds vkxs ¼√½ dk fu’kku yxk;saA vr% vkids
}kjk nh xbZ tkudkjh xksiuh; j[kh tk;sxhA
dksaM ua- ----------------------

1- vk;q ------------------------
v- 20 ls 30 o"kZ ¼ ½
c- 31 ls 40 o"kZ ¼ ½
l- 41 ls 50 o"kZ ¼ ½
n- 50 ls vf/kd ¼ ½

2- fyax ---------------------------------------
v- efgyk ¼ ½
c- iq:"k ¼ ½

3- f’k{kk --------------------------------------------
v- 10 oh ikl ¼ ½
c- 12 oh ikl ¼ ½
l- Lukrd ¼ ½
n- vui< ¼ ½

4- ekfld vk; -----------------------------


v- 2500 ls 5000 :- ¼ ½
c- 5001 ls 7000 :- ¼ ½
l- 7001 ls 10]000 :- ¼ ½
n- 10]000 ls T;knk ¼ ½

57
5- blls igys vkidksa vLirky tfur laØe.k dk Kku dgk ls
feyk\
v- ifjokj@fj’rsnkj ¼ ½
c- nksLrksa ls ¼ ½
l- lekpkj i=@Vsyhfotu ¼ ½
n- LokLF; dk;ZdrkZ ls ¼ ½

58
[k.M ¼c½
1- vLirky tfur laØe.k gS&
v- ?kjksa ls gksus okyk laØe.k ¼ ½

c- m|ksxksa ls gksus okyk laØe.k ¼ ½


l- vLirky ls gksus okyk laØe.k ¼ ½
n- [ksrh ls gksus okyk laØe.k ¼ ½

2- vPNk LokLF; fuHkZj djrk gS&


v- lqjf{kr okrkoj.k ij ¼ ½
c- vlqjf{kr okrkoj.k ij ¼ ½
l- leafer Hkkstu ij ¼ ½
n- buesa ls lHkh ¼ ½

3-vLirky tfur laØe.k dks izHkkofe djus okys dkjd gS&


v- jksxh dh laosnu’khyrk ¼ ½
c- lw{ethoh dkjd ¼ ½
l- i;kZoj.kh; dkjd ¼ ½
n- buesa ls lHkh ¼ ½

4- vLirky tfur laØe.k ds fy, vfr laosnu’khy gS&


v- fpfdRld ¼ ½
c- ulZ ¼ ½
l- jksxh ds laca/kh ¼ ½
n- vLirky deZpkjh fUkEu oxhZ; ¼ ½

5- vLirky tfur laØe.k ls gksus okyh 'olu ra= dh chekjh


gS&
v- fueksfu;k ¼ ½
c- {k; jksx ¼Vh-ch-½ ¼ ½
l- nLr yxuk ¼ ½
n- ihfy;k ¼ ½

6- vkerkSj ij vLirky esa ns[ksa tkuk okyk laØe.k &


v- ew=okfguh laØe.k ¼ ½
c- 'olu ra= laØe.k ¼ ½

59
l- tBjka= laØe.k ¼ ½
n- Ropk laØe.k ¼ ½

60
7- O;fDr esa vLirky tfur laØe.k gksus dk [krjk lcls vf/kd
gksrk gS&
v- de izfrjks/kd {kerk gksus ij ¼ ½
c- [kkyh isV jgus ij ¼ ½
l- jDr dh deh ¼ ½
n- mijksDr lHkh ¼ ½

8- vLirky tfur laØe.k QSyrk gS&


v- Hkkstu }kjk ¼ ½
c- gWlus ls ¼ ½
l- Nhdusa ls ¼ ½
n- xans gksFkksa }kjk ¼ ½

9- fuEu fyf[kr esa ls izR;sd laidZ dk mnkgj.k gS&


v- nwf"kr ikuh ihus ls ¼ ½
c- Nhdusa o [kkWlusa ls ¼ ½
l- dhMs ds dkVus ls ¼ ½
n- gkFk feykus ls ¼ ½

10- buesa ls cawn tfur lapaj.k dk mnkgj.k gS\


v- gWluk ¼ ½
c- jksuk ¼ ½
l- Nhduk ¼ ½
n- Hkkstu djuk ¼ ½

11- osDVj tfur laØe.k dk mnkgj.k gS&


v- laØafer Hkkstu ¼ ½
c- ePNjksa ls ¼ ½
l- loafer ty ls ¼ ½
n- [kklus ls ¼ ½

12- vLirky tfur laØe.k ds eq[; ladsr vkSj y{k.k gS&

61
v- ihfy;ka >Vds vkuk ¼ ½
c- lnhZ]cq[kkj]ukd cguk ¼ ½
l- Fkdku]out de gksuk ¼ ½
n- cky >Muk]dej nnZ ¼ ½

13- vLirky tfur laØe.k dks fUkEUk tkWpksa ds }kjk irk


yx;k tk ldrk gS\
v- [kwu o is’kkc dh tkWp }kjk ¼ ½
c- jDrnko ifj{k.k vkSj isV dh tkWp }kjk ¼ ½
l- ekufld fLFkfr ifj{k.k }kjk ¼ ½
n- ,Dl&js }kjk ¼ ½

14- vLirky tfur laØe.k gksus ij D;k djuk pkfg,&


v- MkWDVj ls laidZ djuk ¼ ½
c- ?kjsyw mipkj djuk ¼ ½
l- tknw Vksuk djuk ¼ ½
n- dqN Hkh ugha ¼ ½

15- vLirky tfur laØe.k ls cpus ds fy, ,d ek= izHkko’kkyh


fof/k gS&
v- deZpkjh dks tkx:d djuk ¼ ½
c- vPNh rjg ls gkFk /kksuk ¼ ½
l- xkmu iguuk ¼ ½
n- ugkuk ¼ ½

16- gesa gkFkksa dh lQkbZ djuk pkfg,&


v fdlh dke dks djus ls igys ¼ ½
c- fdlh dke dks djus ls igys o dke djus ds ckn ¼ ½
l- dke djus ds ckn ¼ ½
n- ejht dks Nwus ds ckn ¼ ½

17- buesa ls nksckjk bLrseky dj ldrs gS &


v- lQkbZ djus okyk diMk ¼ ½
c- ekLd ¼ ½
l- nLrkus ¼ ½
n- xkmu ¼ ½

62
18- gesa lQkbZ ds ckn gkFk /kksuk pkfg,------------ lsA
v- lknsa ikuh ls ¼ ½
c- uy ds uhps cgrs ikuh ls ¼ ½
l- LihfjV ls ¼ ½
n- ,sUVh lsfIVd ?kksy ¼ ½

63
19- gkFk /kksus ds ----------- pj.k gksrs gS&
v- 10 pj.k ¼ ½
c- 7 pj.k ¼ ½
l- pj.k ¼ ½
n- 6 pj.k ¼ ½

20- gkFkksa dks /kksrs le; ----------- f?kluk pkfg,&


v- 1 fefuV ¼ ½
c- 75 lsd.M ¼ ½
l-20 lsd.M ¼ ½
n- 45 lsd.M ¼ ½

21- Lao; dks lqjf{kr j[kus okys midj.kksa dk lgh Øe


gS&
v- ,izkWu]nLrku]ekLd ¼ ½
c- ekLd]XyCl]nLrku ¼ ½
l- ekLd],izkWu]ekLd ¼ ½
n- nLrkus]ekLd],izkWUk ¼ ½

22- Lao; dks lqjf{kr j[kus okys midj.kksa dks iguus dk


lgh Øe gS&
v- ekLd] xkmu] XyCl] vkbZfo;j ¼ ½
c- ekLd] XyCl] xkmu] XyCl ¼ ½
l- ekLd] vkbZfo;j] xkmu] XyCl ¼ ½
n- vkbZfo;j] XyCl] xkmu] ekLd ¼ ½

23- ,aVhcsDVsfj;y lkcwu dks jkstuk mi;ksx lqjf{kr ugha


gS&
v- ;s eWgxs gksrs gS ¼ ½
c- Ropk dks uqdlku gksrk gS ¼ ½
l- vkW[kksa dks uqdlku gksrk gS ¼ ½
n- ;s lHkh ¼ ½

24- vLirky esa --------- jaxksa dh ckWfYV;kW gksrh gS&


v- nks ¼ ½
c- rhu ¼ ½
l- N% ¼ ½

64
n- ikWp ¼ ½

65
25- vLirky esa dpjk izca/ku ds fy, ckfYV;ksa ds jax dh
lwph gS&
v- yky] uhyh] dkyh] ihyh] lQsn ¼ ½
c- xqykch] lQsn] tkequh] Hkwjk] dkyk ¼ ½
l- gjk tkequh] lQsn] xqykch] eg:e ¼ ½
n- larjk] gjk] lQsn] Hkwjk] xqykch ¼ ½

26- uqdhyh oLrq,W Mkyuk pkfg, &


v- yky ckYVh esa ¼ ½
c- uhyh ckYVh esa ¼ ½
l- ihyh ckYVh esa ¼ ½
n- dkyh ckYVh esaa ¼ ½

27- ekuo 'kjhj ds vaxksa o jDrksa dks Mkyuk pkfg,&


v- lQsn ckYVh ¼ ½
c- ihyh ckYVh ¼ ½
l- yky ckYVh ¼ ½
n- dkyh ckYVh ¼ ½

28- vlaØfer dpjk Mkyk tkrk gS&


v- yky ckYVh ¼ ½
c- dkyh ckYVh ¼ ½
l- lQsn ckYVh ¼ ½
n- ihyh ckYVh ¼ ½

29- yky ckYVh esa Mkyuk pkfg,&


v- ?kjsyq dpjk ¼ ½
c- uqdhyh oLrq ¼ ½
l- IykfLVd dh oLrq,W ¼ ½
n- rjy inkFkZ ¼ ½

30-lQsn ckYVh esa Mkyuk pkfg, &


v- lqbZ;k ¼ ½
c- cksrys ¼ ½
l- isij ¼ ½
n- ?kjsyq dpjk ¼ ½

66
iz'u mRRkj
1 Lk
2 v
3 n
4 n
5 c
6 c
7 v
8 n
9 n
10 l
11 c
12 c
13 v
14 v
15 c
16 c
17 v
18 n
19 c
20 l
21 l
`22 l
23 c
24 n
25 v
26 c
27 c
28 c
29 l
30 v
ANNEXURE – VIII
Answer key (Hindi)

67
Annexure - IX
LESSON -PLAN

68
Name of the College - Nandvandan College of Nursing Jabalpur
Subject - Medical Surgical Nursing
Topic - Prevention of Nosocomial Infection
Group - B.Sc. ( Nursing) IV th year
Place - City Hospital, Jabalpur (M.P.)
Time - 11 AM to 12 PM
Teaching Aids - Charts, Flip charts, Pamphlets, Black-
board
Name of Guide - Mrs. Tuleshori Devi

General Objectives—
After the completion of Structured Teaching Programme the Fourth-Class
workers will enhance the knowledge on Nosocomial Infection.
Specific Objective – At the end of the Structured Teaching Programme , the group
will be able to :-
1.) Introduce of the Nosocomial Infection.
2.) Define the Nosocomial Infection.
3.) Explain the Epidemiology Factors.
4.) Explain the route of Transmission of Nosocomial Infection.
5.) Explain the causes of Nosocomial Infection.
6.) Enlist the types of Nosocomial Infection.
7.) List down the sign and symptoms of Nosocomial Infection.
8.) Enlist the diagnosis of Nosocomial Infection.
9.) Explain the Treatment of Nosocomial Infection.
10.) Discuss the Prevention of Nosocomial Infection.
11.) Discuss the Management of Nosocomial Infection.

69
S.NO. SPECIFIC CONTENT TEACHING LEARNER A.V.AIDS EVALUATION
OBJECTIVE TIME ACTIVITY ACTIVITY

1. Introduce of Good health depends in part on a Explaining Listen Leaflets Introduce the
Nosocomial 3 MIN safe environment. Health care and Carefully Nosocomial
Infection. setting are at risk for acquiring Discussing Infection?
infection. The term
“NOSOCOMIAL” comes from
Greek words; “NOSUS” meaning
“to take care of”. Fourth –Class
workers are more susceptible to
have Nosocomial Infection.
To Define the
2. Nosocomial 2 MIN Nosocomial Infection is also Explaining Attend Leaflets Define the
Infection. called “Hospital-acquired and Carefully Nosocomial
Infection”. Is an Infection that is Discussing Infection?
acquired in a hospital or other
care facility.

70
3. To Explain the 4 MIN Epidemiologic Triad – Explaining Show Power point Explain the
Epidemiologic AGENT – The term “Agent” and Interest presentation Epidemiological
al Factor. originally referred to the entity or Discussing Trial?
micro-organism capable of
causing the disease.

HOST

HOST
ENVIRONMENT

HOST – HOST refers to the


organism capable of being
infected by a specific agent.

71
ENVIRONMENT – The
environment is all that is external
to the host.

4. To Explain the 8 MIN Routes of Transmission— Explaining Listen Flip-charts Explain the Route
Route of 1.) Contact Transmission –It is the Carefully of Transmission
Transmission divided into subtype— Discussing of Nosocomial
of Nosocomial A.) Direct Contact – This Infection?
Infection. involves a direct body surface to
body surface.
B.) Indirect Contact – This
involves contact of a susceptible
host with a contaminated object.

2.) Droplet Transmission –


Transmission occur when droplet

72
s containing microbes from the
infected person are propelled a
short distance through droplets.

3.) Airborne Transmission –


Infection Transmitted by either
airborne droplet nuclei of
evaporated droplets containing
micro-organism that remain
suspended in air.

4.) Common Vehicle


Transmission – This applies to
micro-organism tranminated
Iteams, such as food, water.

5.) Vector Borne Transmission—


This occurs when vectors such as
mosquitoes, flies, rats and other

73
vermin transmit micro-organism.

5. Explain the 6 MIN Main causes of Nosocomial Explaining Attend Power point Explain the
causes of are— and Carefully presentation causes of
Nosocomial Bacteria— Bacteria are the main Discussing Nosocomial
Infection. causes of Nosocomial Infection Infection?
.Bacteria constitute a large
domain of micro-organism
bacteria have a no. of shapes.
ranging from spheres to rods and
spirals.

VIRUS – A virus is a small


Infection agent that replicates
only inside the organism cells of
other organism.

PARASITES – Parasites is an
organism lives on in a host and

74
gets its food from or at the
expense of its host parasites in
humans.

FUNGUS – A fungus is any


member of group of eukaryotic
organism includes micro-
organism such as yeasts.

6. To Enlist the 5 MIN Types of Nosocomial Infection – Explaining Listen CHARTS Enlist the types of
types of  Infection of Respiratory and Carefully Nosocomial
Nosocomial Infection – Discussing Infection?
Infection. Nosocomial Infection can
causes no. of respiratory
disease. Respiratory Infection
occur when agent enter into
the respiratory tract.

 Infection of Digestive
system –

75
Nosocomial Infection can
cause digestive system
diseases. When agent enter
into Gastro-intestinal tract
than it causes Digestive
problem.

 Infection of urinary Tract


– Nosocomial Infection
can cause urinary
Infection agent enter into
the urinary tract and
causes common urinary
problems.

 Infection of Cardio-
vascular system—
Nosocomial Infection can
cause cardiac problems
like-Hypertension. When

76
agent enter into the blood
and heart.

 Infection of skin –
Nosocomial Infection can
occur in skin also. When
infectious agent enters
into the skin through sin
mucosa and creates
problems like-Itching,
Swelling, White sports
etc.

 Infection of Sensory
Organ—
It occurs when infectious
agent enter into the Eye,
Nose, Skin, Tounge, Ear.

77
7. To list down 3 MIN Nosocomial Infection shows Explaining Carefully FLIP- List down the
the sign and many sign and symptoms they and CHARTS sign and
symptoms of are – Discussing symptoms of
Nosocomial  Low and High grade Nosocomial
Infection. fever. Infection?
 Nausea, Vomiting,
Diarrhea.
 Redness, Rashes,
Swelling in Legs and and
arms.
 Fatigue, Sleeplessness.
 Sweating.
 Headache, breathing
problem.

8. To Enlist the 3 MIN Diagnosis of Nosocomial Explaining Show Power point Enlist the
Diagnosis of Infection— and Interest presentation Diagnosis of
Nosocomial Discussing Nosocomial
Infection. Many Doctors can diagnose Infection?

78
Nosocomial Infection by sign and
symptoms alone. Inflammation
and rashes at the site of Infection.
Also can detect by—
BLOOD TEST—In blood test
blood sample is taken from
patient and find out the infectious
agent.

URINE EXAMINATION –Urine


examination is done by taking
urine sample ad presence of
Infectious agent is found out.

9 Explain the 2 MIN Treatment of Nosocomial Explaining Listen Pamphlets Explain the
Treatment of Infection— and Carefully Treatment of
Nosocomial If you have any sign and Discussing Nosocomial
Infection. symptoms of Nosocomial Infection?

79
Infection consult with the
Doctors and take proper
treatment as per Doctors order.

10 To Discuss the 8 MIN Prevention of Nosocomial Explaining Attend charts Explain the
Prevention of Infection— and Carefully prevention of
Nosocomial A.) Hand Washing – Discussing Nosocomial
Infection.  Hand washing is a single Infection?
most effective method to
prevent Nosocomial
Infection.
 Wash hands after
touching blood,
secretions, excretion,
contaminated iteams,
whether or not gloves are
worn.
 Wash hands immediately
after gloves are removed.
 Use antiseptic solution for

80
routine hand washing.
 Wash hand before and
after any work.

 There are seven steps in


effective hand washing.
 Rub palms together.
 Rub the back of both
hands.
 Interface fingers and rub
the hands together.
 Interlock fingers and rub
the back of fingers of
both hands.
 Rub thumb in a rotating
manner followed by the
3 area between index finger
and thumb.
 Rub fingertips on palm
for both hands.

81
 Rub both wrists in a
rotating manner rinse and
dry thoroughly.

B.) Use of the Personal


Protective Equipment—
Gloves,Gown,Mask,Eye
Protection Equipment are
personal protective equipment:--

GLOVES--Wear gloves, when


touching blood, body fluids,
secretions, excretions and
contaminated iteams. Do not
reuse the contaminated gloves.
Explain the
GOWN – Wear gloves when Management of
performing patient care activities. Nosocomial
Infection.
MASK, EYE PROTECTION,

82
FACE SHIELD: - Wear a mask
and eye protection or a face
shield during procedure and
patient care activities that are
likely to generate spray of blood.

11. To Discuss the 5 MIN MANAGEMENT:--For Fourth- Explaining Active Charts


Management Class workers waste management and listening
of Nosocomial is important to prevent from Discussing
Infection. Nosocomial Infection.

Bio-medical Waste
Management—

YELLOW BUCKET –
A.)Human Anatomical Waste
B.)Chemical Waste

83
RED BUCKET –
A.)Contaminated waste(
Recyclable)
tubing,bottles,intravenous tubes
and sets,catheters,urine
bages,syringes(without needles)
and gloves.

WHITE BUCKET –
Waste sharps including Metals
(Translucent) Puncture, Leak,
Tamper proof containers.

BLUE BUCKET –
Glassware (Bottles)

BLACK BUCKET –on-


infectious waste like- papers etc.

84
BIBLIOGRAPHY
1. Handbook of Hospital
Acquired Infections.RP
Wenzel, ed. Boca Raton,
Flar CRC Press. Inc: 1981
2. Assessing Quality Health
Care: Perspective for
Clinicians. RP Wenzel,
ed. Baltimore, Md:
Willianms and Wilkins;
1992
3. Prevention and control of
Nosocomial Infections.
4th edition. RP Wenzel,
ed. Baltimore. Lippincott,
Williams and Wilkins;
2003

85
Annexure X

Tools
Section A - Demographic Data Sheet

Age Gender Education Monthly Source


Income Knowledge

1 2 1 1 2 4
2 2 1 1 2 4
3 2 1 1 2 4
4 2 1 1 2 4
5 2 1 1 2 4
6 1 1 1 2 1
7 4 1 2 2 4
8 1 1 2 2 2
9 1 2 1 3 2
10 1 1 2 3 3
11 1 2 2 3 3
12 2 2 2 3 3
13 2 2 2 2 3
14 2 1 1 2 3
15 2 2 2 3 4
16 2 2 2 2 4
17 1 2 1 2 4
18 1 2 1 1 4
19 1 2 1 1 2

86
20 3 1 2 1 4
21 1 1 1 1 4
22 2 1 1 2 4
23 2 1 1 2 4
24 1 2 1 2 2
25 1 2 2 2 2
26 4 1 1 3 2
27 3 1 1 1 3
28 3 1 1 1 1
29 3 2 2 1 3
30 2 2 1 3 4

87
Section A - Demographic Data Sheet

Pre- test Knowledge Scores

Questions Response
Sr.No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Total
0 0 0 1 1 1 1 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 0 0 0 0 1 1 1 0 11 0
1 1 0 0 0 0 1 1 0 1 0 1 1 1 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 1 14 1
1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 1 1 1 0 10 1
0 0 0 0 1 1 1 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 11 0
1 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 11 1
1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 1 0 0 14 1
1 0 0 1 1 1 0 0 0 0 1 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 1 1 1 14 1
1 0 1 1 0 1 1 0 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 10 1
0 0 0 0 1 1 1 0 0 1 1 1 1 0 0 1 1 1 0 0 0 0 1 0 1 0 1 1 0 0 14 0
0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 0 0 1 10 0
0 1 1 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 11 0
1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 1 1 0 0 0 9 1
0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 8 0
0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 1 0 1 1 0 0 1 0 9 0

88
1 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 0 9 1
0 0 1 1 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 1 11 0
1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1 0 1 0 0 10 1
0 1 0 1 1 0 0 1 1 1 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 11 0
1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 1 1 11 1
1 1 1 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 12 1
1 1 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 0 0 1 0 1 0 1 0 1 0 0 10 1
0 0 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 1 0 1 0 0 1 0 1 0 1 1 0 13 0
0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 1 1 0 0 0 9 0
0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 1 1 0 0 1 0 0 11 0
1 0 0 1 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 9 1
1 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 1 0 0 0 1 12 1
0 0 0 1 1 1 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 1 1 0 1 1 0 1 0 0 11 0
0 1 1 0 0 0 0 0 1 1 1 0 0 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 11 0
1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 1 0 0 10 1

89
Post- test Knowledge Scores

Questions Response

Sr.No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Total
0 1 1 1 1 1 1 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 1 1 1 1 0 0 21
1 1 0 1 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 0 0 0 1 1 0 0 0 1 19
1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 0 22
0 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 0 1 1 0 1 1 0 0 0 0 1 1 1 1 1 20
1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 0 0 0 1 0 1 1 1 1 1 1 1 0 0 20
1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 1 0 0 0 1 19
1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 1 22
1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 0 1 21
0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 0 1 1 1 1 0 1 1 1 24
0 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 1 0 1 1 1 1 0 0 1 1 1 1 1 0 0 21
0 1 1 1 1 1 1 1 0 1 0 0 1 0 1 1 0 1 1 0 1 1 1 1 1 1 0 1 1 1 0 22
1 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 0 0 1 0 1 21
0 1 1 1 1 1 0 0 1 1 1 1 0 0 1 1 1 0 1 1 1 1 1 1 0 0 1 1 0 0 1 21
0 1 1 1 1 1 1 1 0 0 0 1 1 1 1 1 0 1 0 1 0 1 1 1 1 1 1 0 1 1 0 22
1 1 1 1 1 1 0 0 0 1 1 1 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 1 21
0 1 1 0 1 1 1 1 0 1 1 1 1 0 1 1 1 0 1 1 0 1 1 1 1 0 1 1 1 0 1 23
1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 0 0 1 0 0 0 1 0 1 1 0 1 1 21
0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 0 0 1 1 23
1 1 1 1 1 1 0 0 0 1 1 1 1 0 0 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 22

90
1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 1 0 0 23
1 1 1 1 1 1 1 1 0 0 1 1 1 1 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 1 22
0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 1 1 0 1 1 0 1 1 0 1 1 1 1 1 0 22
0 1 1 1 1 1 1 1 0 0 0 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 22
0 1 1 1 1 1 0 1 0 0 1 1 1 1 0 0 1 1 1 1 0 1 1 0 1 1 0 1 1 0 1 21
1 1 1 1 1 1 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 20
1 1 1 1 1 0 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 24
0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 0 1 1 1 1 23
0 1 1 1 1 1 0 1 1 1 1 0 1 1 0 1 1 1 1 0 0 1 1 1 1 1 0 0 1 1 1 23
1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 0 0 1 1 0 1 24

91

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