CHAPTER living and life in its fullness. Life is

 CHAPTER IINTRODUCTIONBackgroundof the Study”Whenyou learn something new, the structure of your brain changes”-Jos Walker            Lifeis all about living and life in its fullness. Life is lived only if one livesit happily until the very end of one’s life. For centuries, the brain has fascinated scientists andphilosophers, but until recently they see the brain as something almost incomprehensibleor intangible. However, the brain is beginning to give up its secrets due tothe acceleration of the pace of research. Scientists have learned more aboutthe brain in the last 10 years throughout the previous century.

 The brain is the crownjewel of the human body and considered as delicate, extremely complex andlargest organ, the center for controlling network for various body function. The organ of three pounds is the set ofintelligence, interpreter of the sense, initiator of the corporal movement andcontrol and integration of many activities of the body. Cerebrovascular accidentor stroke, a catastrophic disease is identified as the third leading cause ofdeath, next only to cancer and cardiovascular diseases. It is a paralyzing disease that poses seriousmedical, socioeconomic and rehabilitation problems throughout the world.India faces an enormous socio-economic burden to meet the costs incurred by a stroke since the population is survivingthrough the peak years (55-56) of occurrence of cardiovascular diseases. (Dalal et al.

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1997)  Complications of stroke are the leading causeof death. Despite reduced morbidity in some developed countries, mortality instroke patients is still high worldwide. In the past decades, treatment ofactual stroke has focused on early intervention. However, long-term clinical observations indicate thatpost-stroke pneumonia, cardiovascular complications, and vascular embolism are the main reasons for the higher mortalityrate after stroke.

(Zhang et al. 2014). Stroke remains one of themain causes of death and disability worldwide. The challenges of predicting stroke outcome have been traditionally assessed from a generalpoint of view, where baseline non-modifiable factors such as age or stroke the severity is considered the mostrelevant factors. However, after the onset of the stroke, some specific compilations coulddevelop, such as hemorrhagic transformations or infections after the stroke,which leads to a bad result. An earlyprediction or identification of these circumstances, based on predictive modelsthat include clinical information, could be useful for physicians toindividualize and improve stroke care. (Bustamanteet al.

2016).                Stroke is the fourth leading cause of death in the United States, surpassed only by heart disease, cancer, and chronic lower respiratory disease.It represents an enormous public health and economic burden, estimates at $53.9 billion for direct and indirect costs in 2010. (Roger et al. 2013).

 According to the 2012 American Heart Association, report every yearabout 7,95,000 people experience a new or recurrent stroke (6,10,000 firstattack and 1,85,000 recurrent); by sex,approximately 55,000 more women than men have a stroke. On average, every 40seconds, someone in the United States has a stroke. From 1998 to 2008, thestroke death rate fell 34.8%, and the actual number of stroke deaths decreasedto 19.4%. However, there is still a greater number of annual strokes related topopulation growth and a greater number of older Americans. The ACV for thefirst time for African-Americans is almost double that for Caucasians.

Theage-adjusted rates for stroke by state report a death rate for every 1.00,000from 51.5 to 58.1 for so-called “stroke belt” states that includesthe Carolinas, Georgia, Tennessee, Alabama, Mississippi, Louisiana, Arkansas, and Oklahoma. The stroke belt has the highestincidence of stroke compared to other parts of the country projections by 2030, they suggest that an additional4 million people will suffer a stroke, a 24.9% increase in prevalence as of2010. (Heidenreich et al.

, 2011). Cardiovascular diseases (CVD) have become the leading cause of mortality inIndia. A quarter of all mortality is attributed to CVD. Ischemic heart diseaseand stroke are the predominant causes and are responsible for <80% of deathsfrom CVD. The estimate of the global burdenstudy of the age-standardized CVD mortality rate of 272 per 1, 00,000population in India is higher than the global average of 235 per 1, 00,000.Premature mortality in terms of years of life as a host due to CVD in Indiaincreased by 59% from 23.2 million (1990) to 37 million (2010).

Despite thegreat heterogeneity in the prevalence of cardiovascular risk factors in differentregions, CVD has become one of the leading causes of death in all parts ofIndia, including the poorest states and rural areas. The progression of theepidemic is characterized by the reversal of socioeconomic gradients; Tobaccouse and low intake of fruits and vegetables have become more prevalent amongthose with low socioeconomic levels. In addition, people from lowersocio-economic backgrounds often do not receive optimal therapy, which leads topoorer outcomes. The fight against the epidemic requires the development ofstrategies such as the formulation and effective implementation ofevidence-based policies, the strengthening of health systems and the emphasison prevention, early detection and treatment with the use of conventionaltechniques and not conventional (Drairai and others, 2016).                The first community-based survey in South India was conducted in Vellore on stroke, Tamilnadu during the period 1969-71, followed by a study in Rohtak in northern India during 1971-74.

According to the acute ACV advisory panel of Asia, India is still the rank among countries where information on stroke is minimal. (Banerjee and others 2001). Needfor the Study Stroke is a life-altering event and may involve a prolonged recoveryperiod, which often leaves patients with functional deficiencies that are slowto resolve, stroke survivors and their families constantly report that thepost-discharge period It’s stressful and challenging, like new roles.

Patientsand families often lose the social, emotional and practical support offered byinpatients care for patients returning home to live with their families. There are challenges related to theresumption of activities of daily living, return to work, driving and carryingout daily activities. In addition to changes in the lives of people who suffera stroke, there can also be a significant impact on family members, who maylack the skill and knowledge necessary to fulfill their new roles ascaregivers.

Therefore education,support and skill train to prepare families for their caregiving role are essential to increase participation and safety,clarity expectation, improve quality of life and reduce depression. (Cameron etal.  2013).

 For family caregivers, care is extremely rewarding, creating a bond betweenthe patient and the caregiver. It makes a union that is indispensable for thepatient’s well-being. The caregiver’s well-being depends on the patient’scondition and the level of satisfaction with the circumstances associated withthe care. Undoubtedly, care is a great amount of stress, such as depression,anxiety, and frustration that, if notaddressed, can have a serious impact on the health of the caregiver and evenresent their role too.

(Mustahsan et al, 2014). Stroke is becoming a major cause of premature death and disability in lowand middle-income countries, such asIndia, largely driven by demographic changes and enhanced by the increasingprevalence of the main modifiable risk factors. As a result, developingcountries are exposed to a double burden of communicable and non-communicablediseases. The poor are increasingly affected by stroke, due to the changingexposure of the population to risk factors and, what is more tragic, not beingable to afford the high cost of stroke care.

Most stroke survivors continue tolive with disabilities, and the costs of ongoing rehabilitation and long-termcare are largely borne by family members, who impoverish their families.(Bonita et al, 2007). In an effort to help low- and middle-income countries establish asurveillance system for stroke, the WHO recommended a step-by-step approach(STEPS Stroke) through the use of standardized tools and methods for continuouscare, the compilation of extended and optional data. This system consists ofthree steps that represent the possible outcomes of patients with stroke in thehospital and the community. Step 1: The first step is to collect data onhospitalized patients, such as demographic characteristics, whether it is thefirst recurrent or recurrent stroke, vital status at discharge, treatmentduring the stay, evaluation of risk factors, classification of subtypes andfollow-up until the discharge or death.

Step 2: The second level of the surveyinvolves identifying and collecting information about fatal cases ofnon-hospitalized stroke in the community after proper validation of deathcertificates, verbal autopsy or direct autopsies. Step 3: The third steprepresents non-fatal and non-hospitalized care in the community and is the mostcomplex level of stroke data collection. (Das and others, 2009). Apoplexy has no irrigation or respect for age, race, creed, color, intelligence,and achievement. Education is a vitalaspect of the care and treatment of debilitating diseases, especially strokes.

In a presentation at the New Horizons in Rehabilitation CXZ 2012 Conference, ateam of nurses from Veteran Affairs (VA) evaluated two LCA education programsdeveloped by VA, one administered in person and one based on the web, anddiscovered that both were new important tools to help stroke veterans and theircaregivers control the disease. More than a third of caregivers suffer frompoor health themselves. 29% of women caregivers have missed a job promotiontraining or assignment to care for a stroke survivor. Despite the social support, caregivers feel less stressed,more satisfied, and more able to provide care for longer periods.

(Cheung et al.,2010). Caregivers play an important role throughout the recovery process after thestroke from the first day. Caregivers can be relatives, friends, neighbors and/or health professionals. We have developednumerous resources to help you on this new journey. Caring for stroke survivorscan cause high levels of emotional, mental and physical stress for both thestroke survivor and the caregiver. Besides the anguish, the interruption ofemployment and family life makes care very challenging.

Family caregivers canpromote positive post-stroke recovery outcomes; however, they need to take careof themselves as well. (National Stroke Association, 2017). After a stroke, the patient often suffers varying degrees of disabilitythat require acute treatment for inpatients and long-term care at home.

Therefore, caregivers assume multiple responsibilities that can generatestress, especially when their own needs are not adequately addressed during thepatient’s recovery. It is expected that family caregivers will obtainassistance and information related to the care of professionals during thecourse of the disease. Assessing the needs of family caregivers is importantfor health workers in understanding the problems from the perspective of thecaregiver. Relevant information and advice should be provided to familycaregivers to help them access support when necessary. (Pei and others, 2015). After recovery from stroke, the recurrence rate is high: one in fourstrokes is a recurrence, which implies an increased risk of death than thefirst stroke.

Since recurrent stroke can also be prevented, strategies such asacquiring knowledge of risk factors and modifying lifestyle are crucial forsuccessful prevention. The effective management of risk factors is essentialfor people who have suffered a stroke: their risk of 30 days of a recurrentstroke is 5-12% without timely treatment and reduction of modifiable riskfactors. Adherence to treatment plans to prevent recurrence of stroke isrelatively low (41-52%); In addition, 67-85% of patients with stroke suspendmedical treatment within 3 months after discharge. The rate of adherence tomedications for blood pressure and other treatments is <50% among patientswith stroke. Adherence problems may include a lack of understanding of the sideeffects and action of medications, as well as individual beliefs about theireffectiveness. (Jae et al.

, 2013). ProblemStatementProblem Statement A pre-experimental study to evaluate the effectivenessof the structured education program in the management of home care of patientswith stroke before the knowledge and practice of their caregivers in theselected hospital, Chennai. Objectivesof the Study1.      To assess the pre-test and post-test level of knowledge and practice regarding the management of home care of stroke patients among caregivers.2.      To evaluate the effectiveness of the structured education program in the management of home care of patients with stroke on the knowledge and practice of their caregivers by comparing their level of knowledge and pre-test and post-test practice.

3.      To find the correlation between the level of the knowledge and practice regarding home care management of stroke patient among caregivers.4.      To determine the association between the selected demographic variable of caregivers, the stroke patients and their level of knowledge and practice regarding home care management.

    Operational definitionEffectivenessIn this study, effectivenessrefers to the outcome obtained by the caregivers of patients with stroke afterthe individual teaching as measured in terms of gain in posttest knowledge and practical score. Structurededucation program In this study it refers to the systematically planned, organized andexecuted teaching activity with specific objectives designed for educating thestroke patient caregivers regarding stroke, types of stroke, clinicalmanifestation of stroke, prevention of stroke, nasogastric tube feeding, oralcare,  administration of oralmedications, sponge bath and perineal care, for six days (1 hour / day) throughdemonstration, PowerPoint, charts and educational booklet.  KnowledgeIn this study, it refers to theinformation and level of understanding obtained by the caregivers evaluated in terms of correct responses to the knowledgeitems related to home care management of patients with a stroke which measured by structured knowledge questionnaires developed by the investigator.which includes stroke, types of stroke,clinical manifestation of stroke, prevention of stroke, nasogastric tubefeeding, oral care,  administration oforal medications, a sponge bath, and perineal care. PracticeIn this study, it refers toperformance skill regarding the care provided by the caregivers of the stroke patients as measured by observationchecklist developed by the researcher.

which includesstroke, types of stroke, clinical manifestation of stroke, prevention ofstroke, nasogastric tube feeding, oral care,  administration of oral medications, a sponge bath, andperineal care. HomecaremanagementIt refers to the way the caregiversof patients with stroke take care at home with regard to stroke, types ofstroke, clinical manifestation of stroke, prevention of stroke, nasogastrictube feeding, oral care,  administrationof oral medications, a sponge bath, and perineal care. CaregiversIt refers to the patient’s relatives or paid attendees who take care the immediate needs of the patient with strokeat home after discharge from the hospital. AssumptionsThe studyis based on the assumption thatü  Stroke is a life-threateningcondition.ü  Stroke patient has a riskof poor neurological prognosis.

ü  Stroke affects the patient as well as family.ü  The stroke patientscaregivers will have limited knowledge regarding home care management.ü  Knowledge level influences practice.ü  Teaching on thecare of the patient is a vitalelement to impact the knowledge level and practice. Null HypothesisH01  There will be no significant differences in the level of knowledge andpractice of the pre- and post-test in the management of home care of stroke amongcaregivers.H02 There will be no significant correlationbetween the level of knowledge andpractice regarding home care management of stroke among the caregivers.H03 there will be no significant association between selecteddemographic variables and level of knowledge and practice on home caremanagement of stroke among the caregivers.

 DelimitationThe studyis limited to The caregivers of patients with stroke who are taking care of the patients with stroke admitted in the selected hospital during the time of data collection. The study is limited to only 4 weeks. The study will be limited only to caregivers of stroke patients. Conceptual Framework for the Study               A conceptual framework is a theoretical approach to the study of problems that are scientifically based and emphasizes the disposition of the selection and classification of its concepts. The conceptual framework acts as a building block for the study of research. The overall objective of the framework is to make the scientific findings meaningful and widespread. It provides a certain frame of reference for clinical practice and research.

The objective of this study is the effectiveness of the structured educational program on the management of home care for patients with stroke based on the knowledge and practice of their caregivers. The conceptual framework of the present study was developed by the researcher based on the Goal Achievement Model of Imogene King. (Marrines A. Nursing Theories, 1995). This model focuses on the interpersonal relationship between the caregivers and the nurse, in which interactiontakes place between the nurse and the caregiversand is influenced by the perception of both the nurse and the caregivers. This interaction leads to mutualgoal settings that are to be achieved by the caregivers.In the present study, the interactiontakes place between the investigator and the caregivers of the stroke patient. PerceptionPerception is a process in which the data obtained through the sensesand memory are organized, interpreted and transformed, and are related to pastexperience, the concept of oneself and the educational background.

(Marrines A. Nursing Theories, 1995). In the present study, the researcher and caregivers of stroke patientsperceive the need to acquire knowledge and acquire practice in relation to thetreatment of stroke and the selected procedure, such as nasogastric feeding,oral care and administration of oral medications, bathing sponge, and perineal care. Both the researcher and thecaregiver established the objective of improving the quality of life ofpatients with stroke.   ActionDuring the action phase,the investigator prepares the structured questionnaire schedule to assess theknowledge, an observation checklist to assess the practice and plans for a demonstrationof the selected procedure. The caregiversare motivated to gain knowledge regarding home care management of strokepatients and selected procedure. InteractionIt is the process of perception and communication between the person andthe person, the person and the environment, represented by verbal andnon-verbal behaviors aimed at an objective.

(MarrinesA. Nursing Theories, 1995). During the interaction, the investigator administers a structured questionnaire to assess the knowledge andassesses the practice using an observation checklist.

The caregiver responds tothe structured education program schedule,participates in the structure educational program, and re-demonstrates selectedprocedure on home care management. As a result of this teaching programme, the caregiver and the investigatorenter into the transaction phase. TransactionIt is observablebehaviors of human beings interacting with their environment. When a transaction occurs between the nurse and theclient, goals are attained. (Marrines A.Nursing theories, 1995).

In the present study, thecaregivers gain knowledge and practice upon the selectedprocedure to improve the quality of life regarding home care management. Figure 1: Conceptual Framework on Home Care Managementfor Stroke Patients Based on Imogene King’s Goal Attainment ModelProjectedOutcome of the StudyThe findings of the study will reveal the existing knowledge and practice of caregivers of patients with stroke regarding home care management. The prepared planned teaching programme can be used to educate the caregivers of patients with stroke in the wards and in home settings. The study indicates the need for emphasizing nurse’s responsibility to teach the caregivers of the patients with stroke regarding home care management and selected procedures in their teaching programme and in their respective clinical study. This study will motivate and awaken the interest in health professionals to carry out a comparative study on the role of caregivers with regard to the care of a stroke patient.

SummaryThis chapter has dealt with objectives, operational definitions, assumptions, hypotheses, theoretical framework, delimitations and conceptual framework.Organization of the ReportOther aspects of the study are presented in the following five chapters.CHAPTER II: Review of Literature CHAPTER-III: The research methodology includes research approach, research design, configuration, populations, samples and sampling techniques, tool description, content validity and reliability of tools, pilot study, data collection procedure and plan for analysis of data.CHAPTER – IV: Analysis and interpretation of data.

CHAPTER – V: DiscussionCHAPTER VI: Summary, conclusion, implications, recommendations and limitation.