RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. Name of the Candidate and Address : Riji George

I Year M.Sc Nursing

Mallige Institute of Nursing

Sector-II, HMT Post, Bangalore-13

2. Name of the Institution : Mallige Institute of Nursing

Sector-II, HMT Post, Bangalore-13

3. Course of Study and Subject : I year M.Sc Nursing

Medical Surgical Nursing

4. Date of Admission to Course : 15.06.2011

5. Title of the Topic : “A study to evaluate the effectiveness of self

Instructional Module on knowledge regarding

adverse effects of selected cardiac drugs among staff

nurses at selected hospitals, Bangalore.

1

6. BRIEF RESUME OF THE INTENDED STUDY

6.1. NEED FOR THE STUDY

"If all the medicine in the world were thrown into the sea, it would be bad for the fish and good for

humanity"

- O.W. Holmes

A drug, broadly speaking, is any substance that is absorbed into the body of a living organism, alters

normal bodily function. A drug is "a chemical substance used in the treatment, cure, prevention, or diagnosis

of disease or used to otherwise enhance physical or mental well-being. Drugs may be prescribed for a limited

duration, or on a regular basis for chronic disorders and diseases of all systems1.

Cardiovascular diseases (CVD) are a group of disorders of the heart and blood vessels and include

coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital

heart disease, deep vein thrombosis and pulmonary embolism. Heart attacks are usually acute events and are

mainly caused by a blockage that prevents blood from flowing to the heart 2. Cardiovascular diseases are the

leading cause of death which claims 17.5 million death annually3.

According to the World Health Report 2005, 53% of the deaths were on account of chronic diseases

and 29% were due to cardiovascular diseases alone. It is estimated that by 2020, CVD will be the largest

cause of disability and death in India. The country already has more than 118 million people with

hypertension, which is expected to increase to 213 million by 2025 unless urgent preventive steps are taken.

When people diagnosed with heart diseases, they may be treated with several drugs4.

The variety and scope of cardiovascular drugs have increased tremendously in the past few decades

and new drugs are being approved in the 1950s, effective oral diuretics became available. These drugs

dramatically changed the treatment of heart failure and hypertension. In the mid-1960s a class of agents called

beta blockers was discovered. This led to major changes in physicians’ ability to treat patients with

hypertension or angina pectoris. Calcium Channel blockers and ACE inhibitors became widely used in the

1980s, and they, too, have allowed patients with hypertension, heart failure, and coronary artery disease to be

treated more effectively. The development and use of thrombolytic, the “clot busters,” have revolutionized our

ability to treat patients having heart attack. Digoxin Oral Solution is indicated for the treatment of mild to

moderate heart failure. Even though they are useful in treating cardiovascular disorders and they also have

some side effects5.

Prospective, observational study conducted to estimate the proportion of admissions to a cardiac care

unit (CCU) directly caused by an Adverse Drug Effects (ADE) , 900 consecutive patients admitted to a CCU,

in which ADEs led to admission in 97 of 900 (10.8%) patients. Adverse Drug reactions (ADRs) associated

with prescription or non-prescription drugs caused 63 (7.0%) hospitalizations. The most common prescription

drug ADRs leading to admission were bradycardia (9/42, 21.4%), respiratory distress (7/42, 16.7%), mental

status change (7/42, 16.7%) and bleeding (6/42, 14.3%). CCU admissions due to drugs of abuse

predominantly involved cocaine or alcohol (15/21, 71.4%) leading to hypertensive crisis, tachycardia or heart

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failure (14/21, 66.7%). ADEs as a secondary diagnosis included acute kidney failure (8/22, 36.4%) and

elevated International Normalized Ratio or bleeding (4/22, 18.2%).6

A prospective study conducted to evaluate the types of drug induced adverse cutaneous drug

reactions (ACDRs) in the patients. 65.71% of patients developed ACDRs between 3rd & 10 th days of

administering the drug/s. 31.42% of ACDRs were due to chemotherapeutic agents and 20% were due to

NSAIDS. 31.42% of ACDRs involved urticaria & angioedema and 31.42% exanthamatous rash. None of the

ACDR was fatal. All 100% were male patients had higher incidence (56.21%) of ACDRs than females7.

Public attention is currently focused on (ADRs) as evidenced by a recent bill passed by the US Senate

requiring pharmaceutical companies to provide ADR information to consumers heightened interest in ADRs

was stimulated by the thalidomide tragedy in the 1960s. A Prospective study in USA estimated that 106000

(95% CI, 76000-137000) hospital patients died from an ADR. Thus, they deduced ADRs may rank from the

fourth to sixth leading cause of death8.

An epidemiological study conducted to assess the frequency and type of self reported effects among

hypertensive’s in general population and to estimate the relationship between drug use adverse effect and

healthy utility by using the rating scale method. The result showed that the major side effects of

antihypertensive are emotional distress, insomnia, depression and lethargy. This study concluded that side-

effects among hypertensives are common9

Furosemide, Lasix Related Articles was published by Jay W. Marks about drug interactions. He

pointed out the common side effects of furosemide which includes low blood pressure, dehydration and

electrolyte depletion (for example, sodium, potassium). Less common side effects include jaundice, ringing in

the ears (tinnitus), sensitivity to light (photophobia), rash, pancreatitis, nausea, diarrhoea, abdominal pain, and

dizziness. Increased blood sugar and uric acid levels also may occur10.

A retrospective cohorts study results shows that among 754 heart failure (HF) patients, 50% reported

dizziness, 44% dry cough, 19% nausea, 19% diarrhoea, and 12% gout on the first checklist. Overall, the

likelihood of a medication change was increased by 38% after a perceived adverse effects (AE). Dry cough

had the highest increased likelihood of an associated cardiovascular medication change they concluded that a

considerable number of HF patients perceived possible AE11.

A study conducted to evaluate the frequency and severity of adverse effects resulting from the

administration of streptokinase and alteplase. In this study include 126 consecutive patients who received

standard dosages of these agents for the treatment of acute myocardial infarction. Evaluation was based on

patient assessment by nursing staff, physicians, and the investigators before, during, and after thrombolytic

administration. The results have shown that Overall, adverse effects occurred in 15 (41.7%) of 36 patients

receiving streptokinase and 12 (13.3%) of 90 receiving alteplase (p = 0.001). No major bleeding or neurologic

events were documented. Minor bleeding occurred in 13.9% and 7.8% of streptokinase and alteplase

recipients respectively (p = 0.47), and hypotension in 8 (22.2%) and 5 (5.6%), respectively (p = 0.01). This

study concluded that frequency of hypotension associated with streptokinase was significantly higher than that

with alteplase12.

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A Prospective cohort study conducted on adverse events affecting patients after discharge. 76

patients had adverse events after discharge. Out of 400 study sample (19% [95% CI, 15% to 23%]), 23 had

preventable adverse events (6% [CI, 4% to 9%]) and 24 had ameliorable adverse events (6% [CI, 4% to 9%]).

3% of injuries were serious laboratory abnormalities, 30% were symptoms associated with a no permanent

disability, and 3% were permanent disabilities13.

A study conducted to evaluate the Nurse Practitioner (NP) characteristics and knowledge of drug-

drug interactions (DDIs) . In this study they have taken NP prescribers recruited from a national conference.

The results have shown that NPs correctly classified 31% of drug pairs. Nitro-glycerine and Sildenafil (drug

combination to avoid) was classified correctly by the most respondents (90.8%, n = 305); Warfarin and

Gemfibrozil (drug combination to usually avoid) the fewest 15.7% (n = 302). This study concluded that a

continuing education needs to be targeted to enhance NPs knowledge of potential clinically significant DDIs14.

Medication administration is a basic nursing function that involves skillfull technique and

consideration of the patients development, health status and safety. The nurse administering medications

needs a knowledge base about drugs, including drug names, preparations, classifications, adverse effects and

physiologic factors that affect drug action. Although therapeutic effect is the desired outcome in medication

administration, sometimes secondary undesirable effect occurs. It is important for nurses to monitor the

adverse effects from drug therapy and to educate the clients regarding drugs action and reaction15.

With the light of above facts and findings the researcher, during her clinical experience had come

across patients who were suffering from adverse drug reactions and this experience along with different

reviews, gave the researcher an insight to conduct a study on adverse drug reactions and in order to educate

the nurses .According to 6th right ‘Right to information’ it is important to inform the patient about reactions of

drugs. Hence the researcher felt that there is a need to plan an educational programme on adverse effects of

selected cardiac drugs among staff nurses, which in turn helps to prevent occurrence of secondary

complications of cardiovascular drugs in patient with cardiac diseases. So, with an intense curiosity the

investigator undertake this study to evaluate their knowledge on adverse drug reactions by which a self

instructional module is distributed to the nurses, for helping them to give better patient care.

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6.2. REVIEW OF LITERATUERE

Review of literature is a key step in research process. A review of research and non-research literature

relevant to the study was undertaken which helped the investigator to develop deeper insight into the problem

and gain information what has done in the past.

A randomized preliminary study conducted in 2010; to determine the prevalence rates, risk factors,

and types of treatments used to prevent and treat CVD among a sample of the adult Amish in northern

Indiana. A randomized retrospective chart review (n = 200) from a primary healthcare clinic in a large

Amish settlement was conducted. Prevalence rates were compared to white prevalence American Heart

Association (AHA) 2009. Their results had shown that, the overall CVD prevalence was higher among Amish

men (n = 105) and women (n = 95) compared to white men and women (38.1% and 44.2% vs. 37.2% and

35%, respectively)...This study concluded that CVD and its associated risk factors are a concerning health

problem in the amish of northern Indians16.

A study conducted in 2010; to find out the seriousness, and preventability of adverse drug reactions

(ADRs) of cardiovascular drugs in cardiovascular care unit. In this study they have taken 677 Patients

admitted to cardiovascular care units in which over an eight month period who received at least one

cardiovascular drug. ADRs were recorded based on information collected by interviewing patients, reviewing

patients' charts, laboratory test monitoring, and confirmation by physicians. The relationship between possible

risk factors and ADRs occurrence were assessed by statistical analysis. The results have shown that a total

number of 189 ADRs were registered of which 22.2% were serious. The highest ADR rates were observed

with Streptokinase (59.3%). The rate of preventable ADRs was 6.9%. Multivariate logistic regression analysis

showed that patients with lower weight (OR = 0.95, 95%CI: 0.9-0.99) and patients with smoking history who

had concurrent diseases (OR = 8.72, 95%CI: 1.53-49.52) had a higher risk of experiencing ADRs. This study

concluded that the rate of ADRs induced by cardiovascular drugs was 24.2%. This study has shown that anti-

arrhythmic and thrombolytic agents need more attention17.

A study conducted in 2009 to evaluate the frequency of ADR related admissions and its dependency

on reporting and method of detection, urgency of admissions and included medical departments reflecting

department/hospital type within one study. In this study include 520 randomly selected medical records (3%)

of patients treated in the medical departments of the primary city and tertiary referral governmental hospitals

for certain ADRs causing admissions regarding WHO causality criteria. The results have shown that the

recognized frequency of ADR related admissions also depends on the department's specialty (p = 0.001) and

acceptance of urgently admitted patients (p = 0.001). Patients admitted due to ADRs were significantly older

compared to patients without ADRs (p = 0.025).This study concluded that ADRs cause 5.8% of admissions in

medical departments in the primary city and tertiary referral hospitals in Indiana18.

A standardized case control study conducted in 2007; to evaluate the outcome measures were

association of risk factors for AMI. The samples include 1732 cases with first AMI and 2204 controls

matched by age and sex from 15 medical centres’ in 5 South Asian countries and 10  728 cases and 12 431

controls from other countries. Their results had shown that the mean (SD) age for first AMI was lower in

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South Asian countries (53.0 [11.4] years) than in other countries (58.8 [12.2] years; P<.001). This study

concluded that the prevalence rate of AMI in south Asian countries is lesser than other countries19.

The study conducted in 2007; to determine whether digoxin therapy is associated with increased

mortality in patients with chronic coronary artery diseases. In this study they have taken 8173 patients who

were screened for participation in the Bezafibrate Infarction Prevention (BIP) trial and who survived an acute

myocardial infarction at least 6 months prior to the study. Three-year overall mortality of the 451 (15.5%)

patients receiving digoxin at the time of screening for BIP participation was 22.4% compared to 8.3% in the

patients who did not receive digoxin. The result has shown that cardiac mortality was 16.2% in the digoxin-

treated group, compared to 4.9% in the non-treated patients. This study concluded that the administration of

digoxin to survivors of an acute myocardial infarction in the chronic phase of their disease is statistically

associated with a 30-50% increase in the risk of overall and cardiac mortality during long-term follow-up20.

A study conducted in 2006; to evaluate whether therapy with nitro-glycerine (GTN) would lead to

abnormal coronary artery responses to the endothelium-dependent vasodilator acetylcholine. . Patients were

randomized to continuous transdermal GTN, 0.6 mg/h (n = 8), or no therapy (n = 7), for 5 days prior to a

diagnostic catheterization. Patients had similar risk factors for endothelial dysfunction. The result has shown

that in the morning, the GTN group experienced greater coronary constriction in response to acetylcholine

infusion than those not receiving GTN. This study concluded that therapy with GTN causes abnormal

coronary vasomotor responses to the endothelium-dependent vasodilator acetylcholine, changes that were

persistent for up to 3 hours after GTN discontinuation21.

The randomized study conducted in 2005; to determine equivalent effects of metoprolol and

carvedilol on diurnal heart rate in patients with chronic heart failure. In this study they have taken 51 patients

with chronic heart failure with a mean LVEF 26+1.8% were randomized in a double-blind fashion to receive

metoprolol tart rate 50 mg bid or carvedilol 25 mg bid. 24-h ECG monitoring (Holter) was performed at

baseline, 12 weeks and 1 year. Adequate quality recordings for analysis were obtained from 43 subjects at

baseline, 42 at 12 weeks and 29 subjects at 1 year. The results have shown that Carvedilol exerted a greater

reduction in mortality than metoprolol tart rate in the Carvedilol or Metoprolol European Trial (COMET) and

this study concluded that Metoprolol tart rate 50 mg bid and carvedilol 25 mg bid had similar effects on 24-h

heart rate22.

A study conducted in 2003; to examine the effects of nurse staffing on adverse events, morbidity,

mortality, and medical costs, the study sample included 232 acute care California hospitals and 124,204

patients in 20 surgical diagnosis-related groups. The adverse events included patient fall/injury, pressure ulcer,

adverse drug events, pneumonia, wound infection, and sepsis. Multilevel analysis was employed to examine,

simultaneously, the effects of nurse staffing and patient and hospital characteristics on patient outcomes. The

result has shown that three statistically significant relationships were found between nurse staffing and

adverse events an increase of 1 hour worked by registered nurses (RN) per patient day was associated with an

8.9% decrease in the odds of pneumonia. Similarly, a 10% increase in RN Proportion was associated with a

9.5% decrease in the odds of pneumonia. The occurrence of each adverse events was associated with a

significantly prolonged length of stay and increased medical costs. This study concluded that patients are

6

experiencing adverse events during hospitalization, care systems to reduce adverse events and their

consequences are needed23.

A study conducted in 2001; to determine adverse drug effects, compliance, and initial doses of

antihypertensive drug events (ADEs). In this study they have taken Physicians' Desk Reference (PDR)

because it contains the dosages that are recommended by the drugs' manufacturers and approved by the Food

and Drug Administration, The PDR is the drug reference used most often among physicians; approximately

90% of physicians. The result has shown that the Joint National Committee (JNC) VI recommends

substantially lower initial doses for 23 (58%) of 40 drugs, compared with the PDR. In addition, for 37 (82%)

of 45 drugs, PDR guidelines do not suggest lower initial doses for old or frail patients than for younger adults.

This study concluded that many ADEs occur with the initial dose of antihypertensive drugs; these ADEs were

dizziness, headache, constipation, and low energy24.

A multivariate analysis study conducted in 1995; to determine whether digoxin therapy is associated

with increased mortality in patients recovering from acute myocardial infarction. In this study they have been

taken 1731 survivors of acute myocardial infarction enrolled in the Secondary Prevention Reinfarction

Nifedipine Trial (SPRINT), from which patients with severe heart failure were excluded. The results have

shown that at the time of hospital discharge, 175 patients (10%) were taking digoxin. Mortality over 1 year

after infarction was significantly higher in patients treated with digoxin than in patients who were not

receiving digoxin [27 of 175 (15%) vs. 60 of 1556 (4%); p < 0.0001]. Digoxin administration was associated

with increased mortality in several subsets of patients. This study concluded that the increased mortality risk

may be related to unidentified variables associated with the severity of disease in patients treated with

digoxin. However, their findings raise concern that the administration of digoxin may contribute to increased

mortality in survivors of acute myocardial infarction25.

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6.3. PROBLEM STATEMENT

A Study to evaluate the effectiveness of Self-Instructional Module on knowledge regarding adverse

effects of selected cardiac drugs among staff nurses at selected hospitals, Bangalore.

6.4. OBJECTIVES OF THE STUDY

1. Assess the existing knowledge regarding the adverse effects of selected cardiac drugs among staff nurses

by conducting pretest.

2. Evaluate the effectiveness of self instructional module regarding adverse effects of selected cardiac drugs

among staff nurses by comparing mean pretest and post test knowledge scores

3. Find the association between pretest knowledge scores regarding adverse effects of selected cardiac

drugs among staff nurses with selected socio demographic variables.

6.4.1. HYPOTHESES

H1: There will be significant difference between the pre test and post test knowledge scores among staff

nurses regarding adverse effects of selected cardiac drugs.

H2: There will be significant association between pre test knowledge scores among staff nurses

regarding adverse effects of selected cardiac drugs with selected socio demographic variables.

6.4.2. RESEARCH VARIABLES

Independent Variable: In this study the independent variable refers to Self-Instructional Module on

adverse effects of selected cardiac drugs.

Dependent Variable: In this study the dependent variable is knowledge among staff nurses regarding

adverse effects of selected cardiac drugs.

6.5 OPERATIONAL DEFINITION

Effectiveness:

It refers to the positive changes that the Self Instructional Module will produce on the knowledge

level of staff nurses regarding adverse effects of selected cardiac drugs as evaluated by comparing the pre test

and post test knowledge scores.

Self Instructional Module:

It refers to a planned written material with appropriate visual aids for a person to learn by

himself/herself so as to improve the knowledge regarding adverse effects of selected cardiac drugs.

Adverse effects:

It refers to untoward reactions which occurs in the body due to intake of selected cardiovascular

drugs.

8

Cardiac drugs:

It refers to certain medications used to treat cardiovascular disorders. In this study the cardiac drugs

includes: - Diuretics (Furosemide), Thrombolytic agents (Streptokinase), Inotropic drugs (Digoxin) and

vasodilators (Nitroglycerin).

Staff nurses:

A person who has acquired a diploma or a degree in nursing and presently working at selected hospitals,

Bangalore.

Knowledge:

It refers to the awareness of staff nurses regarding adverse effects of selected cardiac drugs as

measured by the correct responses given to the items in the structured questionnaire.

7. MATERIALS AND METHODS

7.1. SOURCES OF DATA

The data will be collected from staff nurses, working at selected hospitals, Bangalore.

7.2. METHODS OF COLLECTION OF DATA

7.2,1 INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria

Staff nurses who are willing to participate in the study.

Staff nurses who are available at the time of data collection.

Exclusion criteria

Staff nurses who are suffering from physical illness

Staff nurses who are working in O.T

Staff nurses who are not willing to participate in the study.

7.2.2 Research Design:

Quasi experimental, one group pretest- posttest design.

7.2.3 Setting:

Selected hospitals, Bangalore

7.2.4 Sampling technique:

Convenient sampling technique will be used

7.2.5 Sample size:

The sample size will be 50.9

7.2.6 Tools of research:

A structured self administered questionnaire will be prepared and used.

The tool consists of two parts.

Part A: Socio demographic variables.

Part B: Questionnaire on adverse effects of selected cardiac drugs

7.2.7 Collection of data:

The data will be collected by investigator himself/herself by using structured self administered

questionnaire among staff nurses. Later, self instructional module will be distributed to educate them on

adverse effects of selected cardiac drugs. After seven days, post test will be conducted by using same

structured questionnaire to evaluate the effectiveness of self instructional module. The data collection period

will be four weeks.

7.2.8 Method of data analysis and presentation:

Data analysis will be done through descriptive and inferential statistics.

Descriptive statistics: The investigator will use descriptive statistical technique

like mean, median, mode, percentile and standard deviation for data analysis. The analyzed data will

be presented in the form of tables, diagrams and graphs based on findings.

Inferential statistics: Test of significance such as t-test and chi square test will be used depending

on the results obtained.

7.3 Does the study require any investigation to be conducted on patients or other human or

animals? If so, please describe brie

No, the study requires no investigation or intervention on patient or other human beings or animals. This

study includes knowledge assessment of staff nurses and providing self instructional module.

7.4 Has ethical clearance has been obtained from your institution in case of 7.3?

Yes, administrative permission and ethical clearance with regard to study will be obtained from institution and

samples prior to conduct the study.

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8. LIST OF REFERENCES

1. http://en.wikipedia.org/wiki/Drug. Pharmaceutical drugs.

2. Suzzane.c.Smelter,Brenda.G.Bare,Janice.L.Hinkle,Kerry.H.Cheever. Text book of medical surgical

nursing.10th Edition. Lippincott publication. 2000: 713.

3. S. Goenka1, D. Prabhakaran1, V. S. Ajay1, K. S. Reddy2,.Cardiovascular diseases current sciences.

2009 Aug: 10( 97): 367.

4. Rohina Joshi, Stephen Jan, Yangfeng. Global Inequalities in Access to Cardiovascular Health Care.

Journal of American College of cardiology. .2008 Aug: (52): 1817-1825.

5. Lawerence.s.cohen, Jonathan issacsohn, Forrester.Cardiovascular drugs. 283.

6. Heather.A. Wroblewski, James.E. Tisdale, Brian.R. Overhaolser, Joanna.R. Kingery. Hypertension,

lipids prevention adverse drug events resulting in admission to a cardiac unit.2010 Mar 14.

7. Suthar.J, Desai, Karamsad, Suthar and Desai.Adverse cutaneous drug reactions in outdoor patients

attending to Skin & V.D.Department. International Journal of Research in Pharmaceutical and

Biomedical Sciences. 2011 Jan – Mar: 2 (1): 274.

8. Lazarou, J.; Pomeranz, B.H.; Corey. Incidence of adverse drug reactions in hospitalized patients.

Journal of American medical association, 2001 February.

9. Carola Bardage, Dag, Isacson. Self-reported Side-effects of Antihypertensive Drugs.2000: (9): 328-

334.

10. Jay.W.Marks. articles related to furosimide available at http://www.medicininet.com /furosemide/

article.htm. 2009 March.

11. Ruth H.E. De Smedt, Tiny Jaarsma, Flora M. Haaijer-Ruskamp.A study evaluating the Outcomes of

Advising and Counselling in HF. 2010; February: 135-141.

12. Tisdale JE, Colucci RD, Ujhelyi MR, Kluger J, Fieldman. Evaluation and comparison of the adverse

effects of streptokinase and alteplase. 1992.

13. Alan.J.Forster, Harvey.J. Murff,Josh.F.Peterson. The Incidence and Severity of Adverse Events

Affecting Patients after Discharge from the Hospital. 2003 Feb 4: 138(3).

14. Cathrin Carithers. A study of nurse practitioner characteristics and knowledge of drug-drug

interaction 2011 Apr 18.

15. Carol Taylor,carol lillis,Priscilla Lemon,Pamela Lynn.Fundamentals of nursing. Sixth edition.

Lippincott Publication. 2008: (1) : 769

16. Deborah R, Gillum, Beth A. Staffileno.The prevalence of cardiovascular disease and associated risk

factors in the old order amish in northern Indiana. Online Journal of Rural Nursing and Health Care

2010 : ( 10): 2.

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17. Mohebbi N, Shalviri G, Salarifar M, Salamzadeh J, Gholami K. Adverse drug reactions induced by

cardiovascular drugs in cardiovascular care unit patients. Journal of American college of cardiology.

2010 Mar.

18. Miran Brvar, Nina Fokter,Matjaz Bunc, Martin Mozina. The frequency of adverse drug reaction

related admissions according to method of detection, admission urgency and medical department

specialty. Pubmed. 2009.

19. Prashant Joshi, Shofiqul Islam, Prem Pais, Srinath Reddy, Prabhakaran Dorairaj et al. Risk Factors for

Early Myocardial Infarction in South Asians Compared With Individuals in Other Countries. 2007:

286-294.

20. Reicher-Resiss H,jonas M,Boyko V,Shotan A,Goldbourt et al. Are coronary patients at higher risk

with digoxin therapy?. 2008 Feb.

21. Paulo R.A Caramori, Allan G Adelman, Eduardo R Azevedo, Gary E Newton ,,Andrea B Parker et al.

A study to evaluate whether therapy with nitro-glycerin would lead to abnormal coronary artery

responses to the endotheluium-depended vasodilator acetylcholine. 2006 Apr.

22. John E. Sanderson, Leata Y.C. Leung, Skiva K.W. Chan, Gabriel W.K. Yip . Do metoprolol and

carvedilol have equivalent effects on diurnal heart rate in patients with chronic heart failure. 2005:

7(5):874-877.

23. Sung-Hyun Cho, Shaké Ketefian ,Violet H. Barkauskas , Dean G. Smith et al. The Effects of Nurse

Staffing on Adverse events, Morbidity, Mortality, and Medical Costs. 2003: Mar/Apr: 52(2):71.

24. Jay .S. Cohen.Adverse Drug Effects, Compliance, and Initial Doses of Antihypertensive Drugs

Recommended by the Joint National Committee vs. the Physicians' Desk Reference. 2001 Mar 26:

161(6):880-885.

25. Leor J, Goldbourt U, Behar S, Boyko V, Reicher-Reiss H et al. Cardiovasc Drugs. 1995 Aug 9(4).

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9. Signature of the candidate :

10. Remarks of the guide : The research topic selected is appropriate and helps

to enrich the knowledge of staff nurses regarding

adverse effects of selected cardiac drugs which in

turn helps to prevent occurrence of secondary

complications of it.

11. Name and Designation of

11.1. Guide : Mrs. Sakthi Bharathi

Asst. Professor.

Mallige Institute of Nursing,

Sector-II, HMT Post, Bangalore-13.

11.2 Signature :

11.3 Co-guide : Mrs. Padmavathi

Professor , HOD Medical Surgical Nursing

Mallige Institute of Nursing,

Sector-II, HMT Post, Bangalore-13.

11.4 Signature :

11.5 Head of the Department : Mrs.S. Padmavathi,

Professor & Principal,

Mallige Institute of Nursing,

Sector-II, HMT Post, Bangalore-13.

11.6 Signature :

12. Remarks of the Chairman/Principal : The research topic selected is appropriate and it

enhances the knowledge of staff nurses regarding

adverse effects of selected cardiac drugs and helps

them to prevent further complications related to it.

12.1 Signature : 13