Effectiveness of Nursing Strategies on Cardiac parameters among patients with hypotension admitted in Dhanvantri Critical Care Centre, Erode

 

Preethi S.1, Chandramathi K.2, Sampoornam W.3*, N. Ganapathy4

1Nurse Administrator, Dhanvantri Critical Care Centre, Erode.

2Reader, Dhanvantri College of Nursing, Pallakkapalayam.

3Professor, Dhanvantri College of Nursing, Pallakkapalayam.

4Critical Care Physician, Dhanvantri Critical Care Centre, Erode.

*Corresponding Author E-mail: sampoornamwebster@yahoo.co.in

 

ABSTRACT:

Background: Hypotension refers to an abnormally low blood pressure (BP) below 80/60. The role of nursing in treating the patients with hypotension is having a lot of importance. Objectives: To assess the Effectiveness of Nursing Strategies on Cardiac parameters among   patients with hypotension admitted in Dhanvantri Critical Care Centre, Erode. Design: Quasi-experimental design, where Pre and Post test Non equivalent Group design, Setting: Dhanvantri Critical Care Centre, Erode. Methods: Out of 30 patients, 20 patients were selected as experimental group and 10 patients were selected as control group by using purposive sampling technique. Level of cardiac function was measured by cardiac parameters observational scale before and after the procedure. Results: Scores in cardiac function shows, posttest 80% of patients had moderate level of cardiac function in control group whereas on experimental group 95% of patients had normal level of cardiac function. The patient’s level of cardiac parameters improved from the mean value of 12.7±1.59 to 12.5±2.18 in control group and 11.8± 2.07 to 19.2±2.66 in experimental group respectively. Paired ‘t’ test score was 3.462 and 27.49 in control and experimental group. Unpaired ‘t’ test score was 5.44 which is significantly effective. Conclusion: The findings of the study reveal that Fluid therapy and passive leg raising is more effective and it improves the level of cardiac function in patients with hypotension.

 

KEYWORDS: Nursing Strategies, Cardiac Parameters, Patients with Hypotension, Echo Cardiogram, Fluid Therapy, Passive Leg Raising.

 

 


INTRODUCTION:

Hypotension can be caused low blood volume, hormonal changes, widening of blood vessels, medicine side effects, anemia, heart problems or endocrine problems. Reduced blood volume, hypovolemia, is the most common cause of hypotension. This can result from hemorrhage, insufficient fluid intake, as in starvation, or excessive fluid losses from diarrhoea or vomiting. Hypovolemia is often induced by excessive use of diuretics. Hypotension is low blood pressure, especially in the arteries of the systemic circulation.

 

Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Hypotension is generally considered systolic blood pressure less than 80millimeters of mercury (mm Hg) or diastolic less than 60mm Hg. However, in practice, blood pressure is considered too low only if noticeable symptoms are present.

 

According to the National Heart, Lung, and Blood Institute of the National Institute of Health, (2008) hypotension refers to an abnormally low blood pressure (BP) below 80/60. The role of nursing in treating the hypotension patients is having a lot of importance. A meticulous statistical analysis of a large nationwide database concerning Blood pressure and subsequent mortality as a consequence of traumatic injury. The statistical methods used are time-consuming and available for use only in very large data sets (Myofoundation, 2005).

 

National Institute of Health (2014) stated the cardinal symptoms of hypotension which include lightheadedness or dizziness. If the blood pressure is sufficiently low, fainting and often seizures occur. Low blood pressure is sometimes associated with certain symptoms, chest pain, shortness of breath, irregular heartbeat, fever higher than 38.3°C (101°F), headache, stiff neck, severe upper back pain, cough with phlegm, prolonged diarrhea or vomiting, dyspepsia, dysuria, adverse effect of medications, acute, life-threatening allergic reaction, seizures, loss of consciousness, profound fatigue, temporary blurring or loss of vision.

 

Lafanechere A, etal (2006) diagnosis of central hypovolemia tested the value of passive leg raising to predict hemodynamic improvement after fluid expansion in patients with suspected central hypovolemia. Prospective study in four intensive care units at the Amiens university hospital. Thirty-four spontaneously breathing patients with suspected hypovolemia were included and were classified as responders (cardiac output increased by 12% or more after fluid expansion) or non responders. Patients were analyzed in the supine position during 30 degrees leg raising and after fluid expansion. Stroke volume and cardiac output determined by echo cardio graphic and Doppler techniques and heart rate and blood pressure were measured at baseline, during passive leg raising and after fluid expansion. An increase of cardiac output or stroke volume by 12% or more during passive leg raising was highly predictive of central hypovolemia.

 

Hence the researcher felt that nursing strategies (fluid therapy and passive leg raising) is more effective not only to improve the cardiac parameters, but also reduces the usage of medications, reduces the period of hospitalization and prevents complications during hypotension. This further promotes early recovery of the patients and enhances them comfort and promotes early participation in normal life.

 

METHODS:

The research design selected for the present study was a Quasi-experimental design, where Pretest Posttest design was selected to evaluate the effectiveness of nursing strategies on cardiac parameters among patients with hypotension. It is structured like a pretest-posttest randomized experiment, but it lacks the key feature of the randomized designs- random assignment. In Quasi-experimental design, where Pretest Posttest design, both a control group and an experimental group is compared; however, the groups are chosen and assigned out of convenience rather than through randomization. The present study was conducted at Dhanvantri Critical Care Centre Erode. It is 100 bedded private hospital and has highly equipped Echo machine. An average of patient with hypotension admitted in intensive care unit was approximately 20-25 patients per month. The samples selected for the present study were the patients with hypotension. The total sample size was 30 patients, out of which 10 patients were control group and 20 patients were experimental group. All the patients with hypotension in the intensive care unit, during the period of data collection were selected as samples. The investigator selected the experimental group by adopting purposive sampling technique. The experimental group patients were selected from 1-08-2014 to 20-08-2014, whereas control group patients were selected from 21-08-2014 to 30-08-2014. The difference in the selection of control group was after 20 days selection of experimental group. This is to avoid contamination of the samples. This study is based on Imogene King’s Goal Attainment theory, (1997) which would be relevant to improve the level of cardiac parameters by providing nursing strategies among patients hypotension.

 

Inclusion criteria includes age group between 21 and 55 years, both gender, IVC less than 0.5mm, poisoning and envenomation, head injury, acute gastro enteritis, diabetes mellitus, hypothyroidism, bleeding disorder, sepsis, sepsis with bleeding, shock. Exclusion criteria comprises of mechanical ventilation, diuretics drug, referred from other hospitals, aluminium phosphate poisoning, chronic renal failure, left ventricular diastolic dysfunction. Tool consists of demographic characteristics such as age, gender, status of consciousness, associated illness and occupation. Cardiac parameters assessment tool consists of 5 areas like Systolic pressure, Diastolic pressure, IVC Diameter, Stroke Volume and Heart Rate. The content validity of the demographic variables and cardiac parameters were validated by experts and the tool was modified according to the suggestions and recommendations of the experts. The reliability of Cardiac parameters assessment tool was tested by implementing the tool on 4 patients with hypotension at Erode Trust Hospital, Erode. Split Half method was used to test the reliability of the tool. The tool was found to be reliable, (r1 = 0.82).

 

Prior to collection of data, permission was obtained from Managing Director of Dhanvantri Critical Care Centre, Erode. The data was collected from 1-08-2014 to 30-08-2014. The investigator collected the data from both control group and experimental group. Pretest was conducted in Intensive Care Unit by using cardiac parameters observational scale to assess the level of cardiac parameters evaluated by Echo cardiogram. Immediately after pretest the nursing strategies like Fluid therapy (administration of normal saline 1000ml of bolus through the central venous catheter (CVC)/ Intravenous cannulation (IVC) for the duration of 30 minutes once a day in semi recumbent position) followed by passive leg raising (both the legs elevates simultaneously at 45 degree angle for the duration of 5 minutes) were administered.

 

Posttest was conducted by using the same parameters. Descriptive, inferential and non parametric statistics were used to analyze the data. Frequency, percentage, mean, standard deviation, mean percentage, paired‘t’ test, unpaired ‘t’test and Chi square test were applied manually.


 

RESULTS


Table. 1 Frequency and percentage distribution of control and experimental group of patients with hypotension according to their demographic variables.                                 

S. No

Demographic variables

Control group

Experimental group

Frequency

(N1)

Percentage

(%)

Frequency

(N2)

Percentage

(%)

1.

Age in years

a.      21-30 years

 

6

 

60

 

5

 

25

b.     31-40 years

2

20

8

40

c.      41 – 50 years

1

10

5

25

d.      51 -55 years

1

10

2

10

2.

Gender

a.      Male

 

3

 

30

 

9

 

45

b.      Female

7

70

11

55

3.

Status of Conscious

a.      Conscious

 

7

 

70

 

13

 

65

b.      Semiconscious

2

20

2

10

c.      Unconscious

1

10

5

25

4.

Associated illness

a.      Diabetes mellitus

 

0

 

0

1

 

5

b.      AGE (Acute Gastro enteritis)

1

10

1

5

c.      Head injury

0

0

1

5

d.      Poisoning

6

60

9

45

e.      Snake bite

3

30

8

40

5.

Occupation

a)      Medical profession

 

7

 

70

 

10

 

50

b)     Non medical profession

3

30

10

50

 


Table.1 Reveals the frequency and percentage distribution of patients with hypotension according to their demographic variables. Distribution of control and experimental group samples according to their age group depicts that, in control group highest percentage (60%) of them were in the age group of 21 -30 years and lowest similar percentage (10%) of them were in the age group of 41-50 years and 51-55 years respectively. In experimental group the highest percentage (40%) of patients was in the age group of 31-40 years and the similar percentage (25%) of patients were in the age group of 21-30 years and 41-50 years respectively. It might be associated with setting of the study.

 

Distribution of control and experimental group samples according to their gender depicts that, the highest percentage (70% and 55%) of patients with hypotension were females, whereas the lowest percentage (30% and 45%) of patients with hypotension males in control and experimental group. This shows that the highest populations of female patients are undergoing hypotension.

 

Distribution of control and experimental group samples according to their status of consciousness reveals that, both from control group and experimental group the highest percentage (70% and 65%) of patients were conscious. Lowest similar percentages (10% and 10%) of patients were unconscious in control group whereas in experimental group patients were semiconscious.

 

Distribution of control and experimental group of patients according to their associated conditions shows that highest percentage (60% and 45%) of the patients were poisoning in both the groups. In control group lowest percentages (10%) of patients were Acute Gastro Enteritis (AGE) whereas in experimental group only 5% of patients were Diabetes mellitus, Acute Gastro Enteritis (AGE) and head injury respectively.

 

Distribution of control and experimental group of patients according to their occupation shows that, in control group most (70%) of them from medical profession and only 30% of them from non medical profession, whereas 50% from non medical profession and 50% of the from medical profession in experimental.

 

Frequency and percentage distribution of control group pretest and posttest level of cardiac function among patients with hypotension depicts that, in both pretest and posttest majority (80%) of patients had moderate cardiac functions and only 20 of patient had normal cardiac function. It seems that without intervention also there is no change in the level of cardiac parameters among patients with hypotension.

 

Frequency and percentage distribution of experimental group pretest and posttest scores of level of cardiac functions among patients with hypotension depicts that, in pretest majority (9%) of patients had moderate cardiac functions and 10% of patients had normal cardiac functions, whereas in posttest most of them (95%) had normal cardiac functions and 5% of patients had moderate cardiac functions. It seems that nursing strategies on cardiac parameters among patients with hypotension was effective.

 

Frequency and percentage distribution of control group and experimental group posttest scores of level of cardiac functions among patients with hypotension depicts that, in control group majority (80%) of patients had moderate cardiac functions and only 20% of patient had normal cardiac function, whereas in experimental group most of them (95%) had normal cardiac functions and 5% of patients had moderate cardiac functions. It seems that nursing strategies on cardiac parameters among patients with hypotension was effective.


 

Table.2 Comparison of mean, standard deviation, and mean percentage of level of cardiac parameters among control pre and posttest scores

Patients with hypotension

Max scores

Pretest

Posttest

Difference in mean %

Mean

SD

Mean %

Mean

SD

Mean %

Systolic pressure

4

2.2

0.46

55

2.1

0.33

53

2

Diastolic pressure

4

2.2

0.46

55

2.2

0.93

55

0

IVC diameter

4

2.3

0.57

58

2.4

0.66

60

2

Stroke volume

4

2.6

0.66

65

2.6

0.66

65

0

Heart rate

4

3.4

1.15

85

3.2

0.93

80

5

Total

20

12.7

1.59

66

12.5

2.18

63

3

 

Table.3 Comparison of mean, standard deviation, and mean percentage of level of cardiac parameters among experimental pre and posttest scores

Patients with hypotension

Max scores

Pretest

Posttest

Difference in mean %

Mean

SD

Mean %

Mean

SD

Mean %

Systolic pressure

4

2

0.31

50

3.45

0.85

86

36

Diastolic pressure

4

2

0.31

50

3.35

0.88

84

34

IVC diameter

4

2.05

0.22

51

3.45

0.75

86

35

Stroke volume

4

2.5

0.85

63

3.05

0.38

76

13

Heart rate

4

3.

1.12

78

3.7

0.96

93

15

Total

20

11.8

2.07

59

19.25

2.66

96

37

 


Comparison of mean, SD, and mean percentage of control pre and posttest scores reveals that, in control group highest pretest score (3.4±1.59) which is 85% and the posttest score (3.2±0.93)   which is 80% and the mean percentage difference is 5%. Systolic and diastolic pressure had the similar lowest pretest scores (2.2±0.46) which is 55% and the posttest scores was (2.1±0.33 and 2.2±0.93) which is 53% and 55% respectively. The mean percentage difference is 2% for systolic pressure and no difference in diastolic parameters. Similarly the overall mean score was (12.7±1.59), which is 66% where as in posttest the mean score was (12.5±2.18) which is 63%. The mean difference is 3%. It shows that there was untoward disturbance in cardiac parameters of the control group patients.

 

Comparison of mean, SD, and mean percentage of experimental pre and posttest scores reveals that, in experimental group highest pretest score (3.1±1.12) which is 78% and the post test score (3.7±0.96) which is 93% and the mean percentage difference is 15%. Diastolic pressure had the lowest pretest scores (2±0.31) which is 50% and the posttest scores was (3.35±0.88) which is 84. The mean percentage difference is 34%. Similarly the overall mean score was (11.8±2.07), which is 59% where as in posttest the mean score was (19.25±2.66) which is 96%. The mean difference is 37%. It shows that Nursing strategies was effective in improving the cardiac parameters among patients with hypotension.

 

Table.4 Paired ‘t’ test value of pre and posttest scores of level of Cardiac function among control and experimental group

Patients with hypotension

Paired ‘t’ value

Level of significant (P)

Control group

Experimental group

Systolic pressure

4.16

6.79

P < 0.05 significant

Diastolic pressure

3.16

7.33

P < 0.05 significant

IVC diameter

2.826

7.91

P < 0.05 significant

Stroke volume

3.016

4.47

P < 0.05 significant

Heart rate

4.124

3.57

P < 0.05 significant

Total

3.462

27.49

P < 0.05 significant

 

Paired‘t’ test was calculated to analyze the effectiveness between pre and post test scores of control and experimental group on level of cardiac parameters among patients with hypotension. The paired‘t’ test value was 3.462 and 27.49 in control group and experimental group, when compared to table value (2.262 and 2.093) both are high. This shows that there was a significant effectiveness between pre and post test scores of level of cardiac parameters among both control and experimental group, nursing strategies was more effective on cardiac parameters among patients with hypotension, (Table.4).


 

Table.5 Comparison of mean, standard deviation, and mean percentage of level of cardiac parameters among control and experimental group posttest scores

Patients with hypotension

Max scores

Posttest

Difference in mean %

Control group

Experimental group

Mean

SD

Mean %

Mean

SD

Mean %

Systolic pressure

4

2.1

0.33

53

3.45

0.85

86

33

Diastolic pressure

4

2.2

0.93

55

3.35

0.88

84

29

IVC diameter

4

2.4

0.66

60

3.45

0.75

86

26

Stroke volume

4

2.6

0.66

65

3.05

0.38

76

11

Heart rate

4

3.2

0.93

80

3.7

0.96

93

13

Total

20

12.5

2.18

63

19.25

2.66

96

33

 


Comparison of mean, SD, and mean percentage of control and experimental post test scores reveals that, in control group highest pretest score (3.2.±0.93) which is 80% whereas in experimental group posttest score (3.7±0.96) which is 93% and the mean percentage difference is 13%. Systolic pressure had the lowest pretest scores (2.1±0.31) which is 53% and the posttest scores was (3.45±0.88) which is 86. The mean percentage difference is 33%. Similarly the in control group overall mean score was (12.5±2.18), which is 63% where as in experimental group posttest the mean score was (19.25±2.66) which is 96%. The mean difference is 33%. It shows that nursing strategies was effective in improving the cardiac parameters among patients with hypotension. The findings are represented in graphically (Table-5).

 

Table 6: Unpaired‘t’ test value of posttest scores of cardiac parameters in control group and experimental group

Patients with hypotension

Unpaired ‘t’ value

Table value

Level of significant (P)

Systolic pressure

3.23

2.05

P < 0.05 significant

Diastolic pressure

4.14

2.05

P < 0.05 significant

IVC diameter

3.83

2.05

P < 0.05 significant

Stroke volume

5.65

2.05

P < 0.05 significant

Heart rate

4.34

2.05

P < 0.05 significant

Total

5.44

2.05

P < 0.05 significant

 

Unpaired‘t’ test was calculated to analyze the effectiveness between control and experimental groups posttest scores on level of cardiac parameters among patients with hypotension. The unpaired‘t’ test value was 5.44, when compared to table value (2.05, p<0.05), it is high. It seems that there was a significant effectiveness of nursing strategies on cardiac parameters patients with hypotension. (Table: 6).

 

Chi square was calculated to find out the association between control, experimental group posttest scores of the patients with hypotension with their demographic variables (Age, gender, status of conscious, associated conditions and occupation). It reveals there was no significant association (p>0.05) found between the posttest scores of control group when compared to other demographic variables such as age, gender, status of conscious, associated conditions and occupation. Hence the differences observed in the mean scores values were only by chance and not true difference.

 

DISCUSSION:

Cardiac parameter is a great concern that has the potential effect on patient’s health. Nursing strategies (Fluid therapy and Passive leg raising) is one of the most effective therapy which employed by the medical person to overcome cardiac parameters of the patients during hypotension. The findings are: In control group, in both pretest and posttest majority (80%) of patients had moderate cardiac functions and only 20% of patient had normal cardiac function. In experimental group, in pretest majority (90%) of patients had moderate cardiac functions and 10% of patients had normal cardiac functions. In posttest most of them (95%) had normal cardiac functions and 5% of patients had moderate cardiac functions. There was a significant level of cardiac function among patients with hypotension before and after nursing strategies in control and experimental group. In control group Paired‘t’ test value was 3.462, when compared to table value (2.262), it is high. Pretest the mean score was 12.7±1.59, which is 66%. Posttest the mean score was 12.5±2.18, which is 63%. Mean difference was 3%. It seems that without intervention there was no change in the level of cardiac parameters among patients with hypotension. In experimental group Paired‘t’ test value was 27.49, when compared to table value (2.093), it is high. Pretest the mean score was 11.8±2.07, which is 59%. Posttest the mean score was 19.25±2.66, which is 96%. Mean difference was 37%. It seems that nursing strategies was moderately effective on cardiac parameters among patients with hypotension. The un paired ‘t’ test value was 5.44, when compared to table value (2.05), it is high. It seems that there was a significant effectiveness of nursing strategies on cardiac parameters among patients with hypotension. There was a significant effectiveness determine the effectiveness of nursing strategies on cardiac parameters among patients with hypotension in both the groups. Chi square test showed no significant association (P>0.05) with the posttest score of level of cardiac parameters in both control and experimental group with their demographic variables. Hence the differences observed in the mean scores values were only by chance and not true difference. It seems that nursing strategies was effective to all the patients with hypotension irrespective of their demographic variables. There was no significant association between the posttest score of cardiac parameters among patients with hypotension in control and experimental group and their demographic variables.

 

Nursing strategies (Fluid therapy and passive leg raising) can be used by the Nursing professionals who are working in all hospital and clinical settings while doing various medical and surgical procedures. Nursing professionals can use Nursing strategies (Fluid therapy and passive leg raising) as a non pharmacological intervention in case of various situation like hypovolemic shock, low back pain, sciatica pain, etc. Nurse educator should educate the students regarding Nursing strategies (Fluid therapy and passive leg raising) and its implementation. Nurse educator should encourage the Nursing personnel to practice the Nursing strategies (Fluid therapy and passive leg raising) in their clinical settings. Nurse educator should educate the Nursing personnel regarding the complications of hypotension and alternative therapies to overcome hypotension. Nurse administer can review the policies to include Nursing strategies (Fluid therapy and passive leg raising) as a protocol for non pharmacological intervention for cardiac parameters among patients with hypotension. Nurse administer can support the researcher to conduct the research on various problems faced by the hypotensive patients. This study may be issued for further reference. Further large scale study can be done in different settings.

 

RECOMMENDATIONS:

Based on the findings of the study the following recommendations have been made for further study. A study can be conducted with large samples to generalize the findings. Similar study can be conducted without control group. A similar study can be conducted on various cardiac and physiological problems among hypotensive patients like increased pulse rate, temperature, physical discomfort and pain. A comparative study can be conducted to compare the effectiveness of various complementary therapies like music, hypnosis, acupressure, guided imagery, massage therapy among patients with hypotension. Comparative study can be conducted to assess the effectiveness of nursing strategies (Fluid therapy and passive leg raising) among children Vs adult patients with hypotension.

REFERENCES:

1.      National Institute of health, 2008. Diseases and Conditions Index Hypotension. 

2.      Mayo Foundation for Medical Education and Research, 2005. Low blood Pressure (hypotension)-Causes

3.      National Institute of Health, 2014. Diseases and Conditions Index – Hypotension.

4.      Lafanechere A, Pene F, Goulenok C, et al., 2006. Changes in aortic blood flow induced by passive leg raising predict fluid responsiveness in critically ill patients. Crit Care 10 (5):132.

 

 

Received on 21.04.2022         Modified on 24.05.2022

Accepted on 20.06.2022       ©A&V Publications All right reserved

Int.  J. of Advances in Nur. Management. 2022; 10(3):231-236.

DOI: 10.52711/2454-2652.2022.00054