Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.204 (Online Publication: Dec., 2018) BIBECHANA A Multidisciplinary Journal of Science, Technology and Mathematics ISSN 2091-0762 (Print), 2382-5340 (0nline) Journal homepage: http://nepjol.info/index.php/BIBECHANA Publisher: Research Council of Science and Technology, Biratnagar, Nepal Inpatients nursing care provided in a tertiary hospital of Nepal Heera KC1*, Sharmila Shrestha2, Ramananda Chaudhary3, Tara Shah4, Surya B. Parajuli5,6 1Department of Nursing, Purbanchal University-Birat Health College, Biratnagar, Nepal 2Department of Community Health Nursing, B. P. Koirala Institute of Health Sciences, Dharan, Nepal 3Department of Child Health Nursing, B. P. Koirala Institute of Health Sciences, Dharan, Nepal 4Department of Community Health Nursing, B. P. Koirala Institute of Health Sciences, Dharan, Nepal 5Department of Community Medicine, Kathmandu University-Birat Medical College & Teaching Hospital, Morang, Nepal 6Nepal Medical Volunteer Society, Biratnagar, Nepal *E-mail: heerakc2011@gmail.com Article history: Received 05 October, 2018; Accepted 05 November, 2018 http://dx.doi.org/10.3126/bibechana.v16i0.21641 This work is licensed under the Creative Commons CC BY-NC License. https://creativecommons.org/licenses/by-nc/4.0/ Abstract Introduction: Nursing care is necessary for every client seeking any type of healthcare such as health promotion, diagnosis, treatment and recovery. Despite these facts, nurses are given less importance and their works are even unrecognized. Objective: The objective of this study was to explore nursing care provided to inpatients of medical ward at B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Methodology: Hospital based cross-sectional study was carried out in medical ward of B. P. Koirala Institute of Health Sciences, Dharan from Feb 2017 to Oct 2018. Data were retrieved from inpatient admission record book of medical ward of previous 15 months from the initiation of this research work. Admission record book was reviewed and checked for completeness of the record. A total of 290 patients having complete records were enrolled. Collected data were entered in Microsoft excel and analysed by SPSS software. Results: More than half patients (52.8%) were male and 44.8% belonged to Janajati ethnicity. The major age group was 15-25 years (17.9%) with mean and standard deviation of 49.4±20.6. About 28.6 % of the patients were admitted due to cardiovascular related problems and poisoning (13.1%). Most of the patients (67%) were admitted from emergency. Median duration of stay was 4 days. Every 8 out of 10 patients were recovered and discharged. General nursing care provided were maintenance of personal hygiene (91.03%), cannula site care (49.7%), providing psychological support (41%), ambulation (8.3%), back care (7.6%), catheter care(6.9%), passive exercise (2.4%), chest physiotherapy(3.7%), sponge bath(9.3%). Specific care provided were propped-up positioning (36.2%), 2 hourly position change (23.4%), random blood sugar monitoring (12.4%), SpO2monitoring (8.9%), watch for oxygen toxicity (9.3%), weight monitoring (3.1%) and pre CAG (coronary angiography) care(2.1%). Conclusion: Maintenance of personal hygiene, cannula site care, psychological support, two hourly positioning and oral care were the common practices performed. Keywords: Academics and Institutes; Inpatients; Medical Ward; Nursing Care. http://nepjol.info/index.php/BIBECHANA mailto:heerakc2011@gmail.com http://dx.doi.org/10.3126/bibechana.v16i0.20960 https://creativecommons.org/licenses/by-nc/4.0/ https://meshb.nlm.nih.gov/record/ui?name=Academies%20and%20Institutes https://meshb.nlm.nih.gov/record/ui?name=Inpatients Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.205 (Online Publication: Dec., 2018) 1. Introduction Nursing is considered as an art and a science, wherein caring forms the theoretical framework of nursing. Nursing and caring are grounded in a relational understanding, unity, and connection between the professional nurse and the patient. Care in nursing involves the application of art and science through theoretical concepts, scientific research, conscious commitment and purposeful efforts to include caring behaviors during each nurse-patient interaction [1]. The caring process is a fundamental activity of nursing that help attain, maintain, or recover optimal health and quality of life. Nurses are differentiated from other health care providers by their approach to patient care and scope of practices. Nurses practice in many specialities with differing levels of prescription authority [2]. Caring includes cognitive, affective, psychomotor and administrative skills. These skills describes the value of nursing. Nursing is a nurturing profession and caring is the essential component of its holistic practice, especially with the critically ill patient [3]. With better care environment, nurses reported more positive job experiences and patients too had significantly lower risks of death and failure [4, 5]. Various study results indicate missed or omitted nursing care to be an independent predictor of hospital readmissions of patients [6]. For better patient outcome, electronic nursing care reminders are often being used in hospital settings to overcome the missed nursing care and aids in assessing the impact of technology on nursing practice [7]. Evidences show nursing care has led to positive patients’ outcomes of morbidity and mortality across the age continuum. Despite these facts, limited attention has been given to measuring nurses’ actions/behaviors in terms of care that is safe, effective, efficient, equitable, timely, and centered on patients and patients’ families [4, 8]. Just as hospitals and clinicians caring for patients focus carefully on completing accurate diagnosis, appropriate and effective interventions, so do the nurses too in providing nursing care through appropriately planned nursing diagnosis. The proportion of nurses to patients, their qualifications and job description should therefore be carefully planned and managed to manage unnecessary patient death [9]. The roles of nurses have been expanded and resulted in greater job satisfaction and good patient outcome. A study conducted in Australia suggest that patients who had longer nurse consultations were more satisfied (OR=2.50, 95% CI: 1.43-4.35) and more enabled (OR=2.55, 95% CI: 1.45-4.50). Patients who had continuity of care with the same general practice nurse were more satisfied (OR=2.31, 95% CI: 1.33-4.00). Patients who attended practices where nurses worked with broad scopes of practice and high levels of autonomy were more satisfied (OR=1.76, 95% CI: 1.09- 2.82) and more enabled (OR=2.56, 95% CI: 1.40-4.68) than patients who attended practices where nurses worked with narrow scopes of practice and low levels of autonomy. Patients who received nursing care for the management of chronic conditions (OR=2.64, 95% CI: 1.32-5.30) were more enabled than those receiving preventive health care [10]. Due to these facts of nursing care for patient satisfaction and nursing leadership, we need to know the pattern of nursing practices delivered at tertiary care hospital. In tertiary care center, many complicated referral patients are admitted which needs significant nursing care for their better prognosis. Evidence generated from this research will be helpful to formulate Standard operating procedures (SOPs) on nursing care at ward level and entire hospital level. With these facts, we aimed to explore the nursing care provided to inpatients of medical ward at B. P. Koirala Institute of Health Sciences, Dharan, Nepal. 2. Methodology This was a hospital based cross-sectional study carried out in medical ward of B. P. Koirala Institute of Health Sciences, Dharan, Nepal from Feb 2017 to Oct 2018. Data were retrieved from inpatient admission record book of medical ward of previous 15 months from the initiation of this research work. Admission record book was reviewed thoroughly and checked for completeness of the record. A total of Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.206 (Online Publication: Dec., 2018) 290 patients having complete records were enrolled for the study. Collected data were entered in Microsoft Excel and analysed by SPSS software. 3. Results Socio-demographic characteristics of inpatients In table 1, among inpatients in medical ward, more than half were male (52.8%) and 44.8% belonged to Janajati ethnicity. The major age group among the admitted patient was 15-25 years (17.9%) followed by 45-55 years (16.2%) with mean and standard deviation of 49.4±20.6. As depicted by figure 1, majority of inpatients attending at B.P. Koirala Institute of Health Sciences were from Sunsari (35.2%), Jhapa (15.9%) and Morang (15.2%) district. In figure 2, 28.6 % of the patients were admitted due to cardiovascular related problems followed by poisoning (13.1%). Majority (66.5%) of patient were admitted in medical ward from emergency (66.5%) and OPD (14.8%) (table 2). Table 1: Sociodemographic characteristics of the inpatients(n=290). Sex Frequency Percentage Male 153 52.8 Female 137 47.2 Ethnicity Dalit 66 22.8 Janajati 130 44.8 Madhesi 25 8.6 Muslim 5 1.7 Brahmin/Chhetri 64 22.1 Age 15-25 52 17.9 25-35 33 11.4 35-45 42 14.5 45-55 47 16.2 55-65 40 13.8 65-75 44 15.2 75-85 27 9.3 85-95 5 1.7 Mean ± SD 49.4±20.6 Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.207 (Online Publication: Dec., 2018) Fig. 1: Distribution of inpatients visiting from different districts of Nepal (n=290). Pattern of diseases Fig. 2: Pattern of diseases reported among inpatients (n=290). Mode of admission Table 2: Mode of admission of inpatients (n=290). Mode of admission Frequency Percentage Outpatient department (OPD) 43 14.8 Emergency 193 66.5 Transfer from other wards 24 8.3 Transfer from ICU/CCU 30 10.4 15.9 5.2 35.2 1.7 15.2 8.6 2.4 3.8 4 1.7 0.7 4.1 1.4 2.8 0 5 10 15 20 25 30 35 40 India Taplejung Ilam Udaypur Bhojpur Khotang Dhankuta Panchthar Saptari Morang Tehrathum Sunsari 0 5 10 15 20 25 30 12.1 28.6 8.6 1.4 8.3 3.8 9 2.1 3.1 13.1 2.8 0.7 2.4 1 2.1 0.3 0.3 0.3 Percentage % Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.208 (Online Publication: Dec., 2018) Nursing care provided Table 3: Nursing care provided to inpatients (n=290). Nursing care Frequency Percentage General care I/V cannula site care 144 49.7 Back care 22 7.6 Intake output 290 100.0 Personal hygiene 264 91.03 Sponge bath 27 9.3 Health education on particular disease 42 14.5 Psychological support 119 41.0 Passive exercise 7 2.4 Ambulation 25 8.6 Chest physiotherapy 11 3.7 Specific care Positioning-propped up 105 36.2 Watch for oxygen toxicity 27 9.3 2 hourly position change 68 23.4 Watch for UGI bleeding 10 3.4 Dressing for thrombophlebitis 1 0.3 Catheter care 20 6.9 Observe for bradycardia 1 0.3 Endotracheal tube care 1 0.3 Cardiac monitoring 5 1.7 Weight monitoring 9 3.1 Leg elevation 2 0.7 Abdominal girth charting 3 1.0 Cold sponging 2 0.6 SPO2 monitoring 36 12.41 N/G tube feeding 4 1.2 ECG 4 1.2 Diabetic foot care 1 0.3 Preoperative care for CAG 6 2.1 RBS monitoring 41 14.13 Wound Care 2 0.6 Nursing care provided to inpatients were divided to general care and specific care which is shown in table 3. Majority (91.03%) of inpatients received the care related to maintenance of personal hygiene (hair care, nail care, oral care and grooming). Intravenous cannula (I/V) site care was provided to 49.7% of the inpatients based on their need. Maintenance of intake output pattern was received by all patients. Forty one percent of the patients were provided reassurance while almost 15 % inpatient received health education on particular disease. Concerning specific nursing care 36.2 % patients were provided to maintain their position to ease their breathing, 23.2% were changed position 2 hourly and SPO2 monitoring was done among 12.41%. Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.209 (Online Publication: Dec., 2018) Outcome of patients Table 4: Outcome of inpatients (n=290). Outcomes Frequency Percentage Recovered and discharge 223 76.9 Expired 10 3.4 Leave against medical advice (LAMA) 14 4.8 Discharge on patient request (DOPR) 19 6.6 Refer to another hospital 3 1 Transfer to another ward 14 4.8 Transfer to ICU/CCU 7 2.4 Duration of hospital stay Range: 1-35 days Median: 4 days 4. Discussion A hospital based cross-sectional study was conducted in medical ward of B. P. Koirala Institute of Health Sciences. Admission record book was reviewed thoroughly and checked for completeness of the record of which 290 patients having complete records were enrolled for the study. In present study, majority (91.03%)of inpatients received the care related to maintenance of personal hygiene (hair care, nail care, oral care and grooming). Oral care is one of the important nursing care among inpatients of medical ward. In a systematic review, it was found that oral hygiene have an impact on incidence and outcomes of respiratory diseases like pneumonia and chronic obstructive pulmonary disease in people living in the community and in long-term health care facilities. Such incidence can be reduced by oral hygiene measures [11]. Similarly another study conducted in Canada supports the importance of oral care that explains a positive body image and the perception of adequate oral health are linked to increased social contacts, as well as improved health and well-being irrespective of age [12]. A study reported that oral health have an impact on daily performances where they identified difficulty of eating and enjoying food (42.3%), and speaking and pronouncing clearly (10.3%)due to inadequate oral care [13]. Thus nursing personnel should provide oral care as it is one of the important nursing care to improve overall patient outcome at hospitals. In this study, one third of patients received specific nursing care that is two hourly position change. This is an important specific nursing care for bed ridden patients to prevent pressure sores which was evident by a research conducted at Sweden where nursing staff used to reposition the patients who were high risk than those assessed as low risk. This led to the conclusion that repositioning and positions used in the prevention of pressure ulcers is important [14]. A research study found that, patients were repositioned frequently during the day and evening and least at night time [15]. Pressure ulcers can predispose to a variety of complications that include bacteremia, osteomyelitis, squamous cell carcinoma, and sinus tracts. The three components of pressure ulcer prevention that must be considered in any patient include management of incontinence, nutritional support, and pressure relief. Various electronic devices and materials have been practiced to prevent pressure ulcer [16]. However in low income countries where such devices can’t be affordable and approachable carefully Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.210 (Online Publication: Dec., 2018) planned nursing care can contribute to prevent the pressure sores. In this study, intravenous cannula site care was provided to 49.7% of the inpatients based on their need. Similar finding was revealed in a hospital based study conducted at Johor, Malaysiawhere83.7% followed the correct practice of care and maintenance of IV cannula. The researcher also suggested that nurses should know about this vital procedure in order to prevent risk and complication to the patient. Therefore, IV cannula site care is one of the important nursing care and it should be followed correctly [17]. In this study maintenance of intake output was received by all patients. A research suggested that advanced heart failure, renal diseases are often associated with a variety of hemodynamic, fluid, and electrolyte derangements. This involves vigilant assessment of hydration, fluid treatment plan personalized for the specific patient, repeated and frequent reassessment of fluid and electrolyte balance, and appropriate changes in the treatment plan in response to the rapidly changing clinical situation of the patient that cannot be maintained by clinicians along. Hence Nursing care is utmost to such patients [18]. It helps the inpatients for better clinical outcome. In the present study 36.2 % patients were kept in propped up position to ease their breathing and SPO2 monitoring was done among 12.41%. Likewise study conducted in Australia found elevation of the head of the bed (1-45°) was the most frequently adopted position[15]. Present study also identified catheter care(6.9%), chest physiotherapy (3.7%), ambulation (8.6%), nasogastric tube feeding (1.2%), preoperative care (2.1%) and diabetic foot care(0.3%) as important nursing care provided to the patient. Forty one percent of the patients were provided psychological support while almost 15 % inpatient received health education on particular disease. In a study the mean total ‘Satisfaction with Nursing Care Scale’ score was 62.08 ± 20.94, and the mean total ‘Experience of Nursing Care Scale’ was 71.97 ± 11.97. The highest satisfaction items were reported as ‘the skillfulness of nurses’ and ‘the nurses’ respect for the patients’ privacy’ concluding that patients require more individualized care from nurses regarding education, communication and comfort [19]. This suggests that nursing care is fundamental for patient satisfaction and positive image with hospital environment, rapid recovery and wellbeing. Additionally, this study found that almost 8 out of 10 patients were recovered and discharged. The World Alliance for Patient Safety reported that 10% of hospital patients in developed countries suffer an adverse event each year [20]. This is a good sign of care. Patient outcome depends upon care provided by various discipline that is medical doctors, nursing professionals, paramedics, supporting staffs and even administration. It is evident that, nursing care is vital for better prognosis. In support to this, a research found that routine use of care maps was used to minimize unnecessary patient death [9]. 5. Conclusion Maintenance of personal hygiene, intravenous cannula site care, psychological support and two hourly positioning were common practice performed. Recommendations Individual level disease specific nursing care research needs to be done in a large setting. Nursing care practices should be studied by using various nursing care tools and guidelines to identify the applicability and effectiveness. Limitation of the Study This research could not identify individual level nursing care based on disease pattern. The impact on patient outcome due to nursing care could not be established. Heera KC et al. / BIBECHANA 16 (2019) 204-212: RCOST p.211 (Online Publication: Dec., 2018) Acknowledgement The authors would like to acknowledge nursing officer and ward staffs of medical ward of B. P. Koirala Institute of Health Sciences, Dharan. Conflict of Interest We declare no conflict of interest. Financial Disclosure No grant or financial support has been received for this research work. References [1] T. Jasmine, Art, science, or both? Keeping the care in nursing, The Nursing clinics of North America 44(4) 2009415-21. PubMed PMID: 19850178. Epub 2009/10/24. eng. [2] P. F. Martins, M.G. 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