CHAPTER living and life in its fullness. Life is



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of the Study

you learn something new, the structure of your brain changes”

Jos Walker

is all about living and life in its fullness. Life is lived only if one lives
it happily until the very end of one’s life. For centuries, the brain has fascinated scientists and
philosophers, but until recently they see the brain as something almost incomprehensible
or intangible. However, the brain is beginning to give up its secrets due to
the acceleration of the pace of research. Scientists have learned more about
the brain in the last 10 years throughout the previous century.


The brain is the crown
jewel of the human body and considered as delicate, extremely complex and
largest organ, the center for controlling network for various body function. The organ of three pounds is the set of
intelligence, interpreter of the sense, initiator of the corporal movement and
control and integration of many activities of the body.


Cerebrovascular accident
or stroke, a catastrophic disease is identified as the third leading cause of
death, next only to cancer and cardiovascular diseases. It is a paralyzing disease that poses serious
medical, 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 surviving
through the peak years (55-56) of occurrence of cardiovascular diseases. (Dalal et al. 1997)

 Complications of stroke are the leading cause
of death. Despite reduced morbidity in some developed countries, mortality in
stroke patients is still high worldwide. In the past decades, treatment of
actual stroke has focused on early intervention. However, long-term clinical observations indicate that
post-stroke pneumonia, cardiovascular complications, and vascular embolism are the main reasons for the higher mortality
rate after stroke. (Zhang et al. 2014).


Stroke remains one of the
main causes of death and disability worldwide. The challenges of predicting stroke outcome have been traditionally assessed from a general
point of view, where baseline non-modifiable factors such as age or stroke the severity is considered the most
relevant factors. However, after the onset of the stroke, some specific compilations could
develop, such as hemorrhagic transformations or infections after the stroke,
which leads to a bad result. An early
prediction or identification of these circumstances, based on predictive models
that include clinical information, could be useful for physicians to
individualize and improve stroke care. (Bustamante
et 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 year
about 7,95,000 people experience a new or recurrent stroke (6,10,000 first
attack and 1,85,000 recurrent); by sex,
approximately 55,000 more women than men have a stroke. On average, every 40
seconds, someone in the United States has a stroke. From 1998 to 2008, the
stroke death rate fell 34.8%, and the actual number of stroke deaths decreased
to 19.4%. However, there is still a greater number of annual strokes related to
population growth and a greater number of older Americans. The ACV for the
first time for African-Americans is almost double that for Caucasians. The
age-adjusted rates for stroke by state report a death rate for every 1.00,000
from 51.5 to 58.1 for so-called “stroke belt” states that includes
the Carolinas, Georgia, Tennessee, Alabama, Mississippi, Louisiana, Arkansas, and Oklahoma. The stroke belt has the highest
incidence of stroke compared to other parts of the country projections
by 2030, they suggest that an additional
4 million people will suffer a stroke, a 24.9% increase in prevalence as of
2010. (Heidenreich et al., 2011).


Cardiovascular diseases (CVD) have become the leading cause of mortality in
India. A quarter of all mortality is attributed to CVD. Ischemic heart disease
and stroke are the predominant causes and are responsible for <80% of deaths from CVD. The estimate of the global burden study of the age-standardized CVD mortality rate of 272 per 1, 00,000 population 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 India increased by 59% from 23.2 million (1990) to 37 million (2010). Despite the great heterogeneity in the prevalence of cardiovascular risk factors in different regions, CVD has become one of the leading causes of death in all parts of India, including the poorest states and rural areas. The progression of the epidemic is characterized by the reversal of socioeconomic gradients; Tobacco use and low intake of fruits and vegetables have become more prevalent among those with low socioeconomic levels. In addition, people from lower socio-economic backgrounds often do not receive optimal therapy, which leads to poorer outcomes. The fight against the epidemic requires the development of strategies such as the formulation and effective implementation of evidence-based policies, the strengthening of health systems and the emphasis on prevention, early detection and treatment with the use of conventional techniques 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).  Need for the Study Stroke is a life-altering event and may involve a prolonged recovery period, which often leaves patients with functional deficiencies that are slow to resolve, stroke survivors and their families constantly report that the post-discharge period It's stressful and challenging, like new roles.Patients and families often lose the social, emotional and practical support offered by inpatients care for patients returning home to live with their families. There are challenges related to the resumption of activities of daily living, return to work, driving and carrying out daily activities. In addition to changes in the lives of people who suffer a stroke, there can also be a significant impact on family members, who may lack the skill and knowledge necessary to fulfill their new roles as caregivers. 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 et al.  2013).   For family caregivers, care is extremely rewarding, creating a bond between the patient and the caregiver. It makes a union that is indispensable for the patient's well-being. The caregiver's well-being depends on the patient's condition and the level of satisfaction with the circumstances associated with the care. Undoubtedly, care is a great amount of stress, such as depression, anxiety, and frustration that, if not addressed, can have a serious impact on the health of the caregiver and even resent their role too. (Mustahsan et al, 2014).   Stroke is becoming a major cause of premature death and disability in low and middle-income countries, such as India, largely driven by demographic changes and enhanced by the increasing prevalence of the main modifiable risk factors. As a result, developing countries are exposed to a double burden of communicable and non-communicable diseases. The poor are increasingly affected by stroke, due to the changing exposure of the population to risk factors and, what is more tragic, not being able to afford the high cost of stroke care. Most stroke survivors continue to live with disabilities, and the costs of ongoing rehabilitation and long-term care 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 a surveillance system for stroke, the WHO recommended a step-by-step approach (STEPS Stroke) through the use of standardized tools and methods for continuous care, the compilation of extended and optional data. This system consists of three steps that represent the possible outcomes of patients with stroke in the hospital and the community. Step 1: The first step is to collect data on hospitalized patients, such as demographic characteristics, whether it is the first recurrent or recurrent stroke, vital status at discharge, treatment during the stay, evaluation of risk factors, classification of subtypes and follow-up until the discharge or death. Step 2: The second level of the survey involves identifying and collecting information about fatal cases of non-hospitalized stroke in the community after proper validation of death certificates, verbal autopsy or direct autopsies. Step 3: The third step represents non-fatal and non-hospitalized care in the community and is the most complex 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 vital aspect of the care and treatment of debilitating diseases, especially strokes. In a presentation at the New Horizons in Rehabilitation CXZ 2012 Conference, a team of nurses from Veteran Affairs (VA) evaluated two LCA education programs developed by VA, one administered in person and one based on the web, and discovered that both were new important tools to help stroke veterans and their caregivers control the disease. More than a third of caregivers suffer from poor health themselves. 29% of women caregivers have missed a job promotion training 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 the stroke from the first day. Caregivers can be relatives, friends, neighbors and/or health professionals. We have developed numerous resources to help you on this new journey. Caring for stroke survivors can cause high levels of emotional, mental and physical stress for both the stroke survivor and the caregiver. Besides the anguish, the interruption of employment and family life makes care very challenging. Family caregivers can promote positive post-stroke recovery outcomes; however, they need to take care of themselves as well. (National Stroke Association, 2017).   After a stroke, the patient often suffers varying degrees of disability that require acute treatment for inpatients and long-term care at home. Therefore, caregivers assume multiple responsibilities that can generate stress, especially when their own needs are not adequately addressed during the patient's recovery. It is expected that family caregivers will obtain assistance and information related to the care of professionals during the course of the disease. Assessing the needs of family caregivers is important for health workers in understanding the problems from the perspective of the caregiver. Relevant information and advice should be provided to family caregivers to help them access support when necessary. (Pei and others, 2015).   After recovery from stroke, the recurrence rate is high: one in four strokes is a recurrence, which implies an increased risk of death than the first stroke. Since recurrent stroke can also be prevented, strategies such as acquiring knowledge of risk factors and modifying lifestyle are crucial for successful prevention. The effective management of risk factors is essential for people who have suffered a stroke: their risk of 30 days of a recurrent stroke is 5-12% without timely treatment and reduction of modifiable risk factors. Adherence to treatment plans to prevent recurrence of stroke is relatively low (41-52%); In addition, 67-85% of patients with stroke suspend medical treatment within 3 months after discharge. The rate of adherence to medications for blood pressure and other treatments is <50% among patients with stroke. Adherence problems may include a lack of understanding of the side effects and action of medications, as well as individual beliefs about their effectiveness. (Jae et al., 2013).   Problem Statement Problem Statement A pre-experimental study to evaluate the effectiveness of the structured education program in the management of home care of patients with stroke before the knowledge and practice of their caregivers in the selected hospital, Chennai.   Objectives of the Study 1.      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 definition Effectiveness In this study, effectiveness refers to the outcome obtained by the caregivers of patients with stroke after the individual teaching as measured in terms of gain in posttest knowledge and practical score.   Structured education program In this study it refers to the systematically planned, organized and executed teaching activity with specific objectives designed for educating the stroke patient caregivers regarding stroke, types of stroke, clinical manifestation of stroke, prevention of stroke, nasogastric tube feeding, oral care,  administration of oral medications, sponge bath and perineal care, for six days (1 hour / day) through demonstration, PowerPoint, charts and educational booklet.   Knowledge In this study, it refers to the information and level of understanding obtained by the caregivers evaluated in terms of correct responses to the knowledge items 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 tube feeding, oral care,  administration of oral medications, a sponge bath, and perineal care.   Practice In this study, it refers to performance skill regarding the care provided by the caregivers of the stroke patients as measured by observation checklist developed by the researcher. which includes stroke, types of stroke, clinical manifestation of stroke, prevention of stroke, nasogastric tube feeding, oral care,  administration of oral medications, a sponge bath, and perineal care.   Homecare management It refers to the way the caregivers of patients with stroke take care at home with regard to stroke, types of stroke, clinical manifestation of stroke, prevention of stroke, nasogastric tube feeding, oral care,  administration of oral medications, a sponge bath, and perineal care.   Caregivers It refers to the patient's relatives or paid attendees who take care the immediate needs of the patient with stroke at home after discharge from the hospital.   Assumptions The study is based on the assumption that ü  Stroke is a life-threatening condition. ü  Stroke patient has a risk of poor neurological prognosis. ü  Stroke affects the patient as well as family. ü  The stroke patients caregivers will have limited knowledge regarding home care management. ü  Knowledge level influences practice. ü  Teaching on the care of the patient is a vital element to impact the knowledge level and practice.   Null Hypothesis H01  There will be no significant differences in the level of knowledge and practice of the pre- and post-test in the management of home care of stroke among caregivers. H02 There will be no significant correlation between the level of knowledge and practice regarding home care management of stroke among the caregivers. H03 there will be no significant association between selected demographic variables and level of knowledge and practice on home care management of stroke among the caregivers.   Delimitation The study is 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 interaction takes place between the nurse and the caregivers and is influenced by the perception of both the nurse and the caregivers. This interaction leads to mutual goal settings that are to be achieved by the caregivers. In the present study, the interaction takes place between the investigator and the caregivers of the stroke patient.   Perception Perception is a process in which the data obtained through the senses and memory are organized, interpreted and transformed, and are related to past experience, the concept of oneself and the educational background. (Marrines A. Nursing Theories, 1995).   In the present study, the researcher and caregivers of stroke patients perceive the need to acquire knowledge and acquire practice in relation to the treatment 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 the caregiver established the objective of improving the quality of life of patients with stroke.       Action During the action phase, the investigator prepares the structured questionnaire schedule to assess the knowledge, an observation checklist to assess the practice and plans for a demonstration of the selected procedure. The caregivers are motivated to gain knowledge regarding home care management of stroke patients and selected procedure.   Interaction It is the process of perception and communication between the person and the person, the person and the environment, represented by verbal and non-verbal behaviors aimed at an objective. (Marrines A. Nursing Theories, 1995). During the interaction, the investigator administers a structured questionnaire to assess the knowledge and assesses the practice using an observation checklist. The caregiver responds to the structured education program schedule, participates in the structure educational program, and re-demonstrates selected procedure on home care management. As a result of this teaching programme, the caregiver and the investigator enter into the transaction phase.   Transaction It is observable behaviors of human beings interacting with their environment. When a transaction occurs between the nurse and the client, goals are attained. (Marrines A. Nursing theories, 1995). In the present study, the caregivers gain knowledge and practice upon the selected procedure to improve the quality of life regarding home care management. Figure 1: Conceptual Framework on Home Care Management for Stroke Patients Based on Imogene King's Goal Attainment Model Projected Outcome of the Study The 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.