RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

NAME AND ADDRESS OF THE Mr.A. AMRUTH RAJA REDDY

1. 1 CANDIDATE
1ST YEAR MSc NURSING

KNN COLLEGE OF NURSING

YELAHANKA, BANGALORE

NAME OF THE KNN COLLEGE OF NURSING,

2 INSTITUTION
CA 23/B, A SECTOR, SATELITE TOWN,

YELAHANKA, BANGALORE-64

COURSE OF THE STUDY AND 1ST YEAR M.SC (NURSING)

3 THE SUBJECT MEDICAL SURGICAL NURSING

DATE OF ADMISSION 28-6-2012

4

EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAMME ON SWALLOWING EXRCISES FOR
TITLE OF THE STUDY DYSPHAGIA.
5
6. BRIEF RESUME OF THE INTENDED WORK

6.1.INTRODUCTION
“ BUT FOR EVERY MAN THEIR EXIST A BAIT WHICH HE CAN’T
RESIST SWALLOWING”
FREIDRICHNIETZSCHEU
Eating is the ingestion of food, to provide nutritional or medicinal needs,
particularly for energy and growth. Swallowing is the process in the human or animal body that
makes something pass from the mouth, to the pharynx and into the oesophagus while shutting the
epi-glottis. If this fails and the object goes through the trachea, then choking or pulmonary
aspiration can occur. In the human body it is controlled by the swallowing reflex. 1
Dysphagia derived from the greekphagein, meaning ‘to eat’, is a common symptom
of head and neck cancer and can be an unfortunate sequelae of its treatment. It may also occur in
stroke patients. Dysphagia is any disruption in the swallowing process during bolus transport
from the oral cavity to the stomach. 2A stroke is an interruption of the blood supply to any part
of the brain. A stroke is sometimes called a Brain attack. There are two major types of stroke –
Ischemic & Hemorrhagic stroke. Stroke is defined by WHO as a rapidly developing syndrome
with clinical signs of focal or global disturbance of Cerebral functions with symptoms lasting 24
hours or longer or Leading to death with no apparent cause other than vascular origin.3
According to WHO, stroke kills 17 million people a year, which is almost one third of all deaths
globally.4
The conditions may manifest as headache, Changes in alertness, dysphagia,
shoulder pain, neck pain, vertigo, Loss of co-ordination, numbness or tingling on affected side,
Decreased vision ,trouble speaking & trouble walking. The clinical aspects of dysphagia after
stroke, it is worth considering what exactly is meant by the term dysphagia. In the context of
stroke, oropharyngeal dysphagia is probably best defined as a disruption of bolus flow through
the mouth and pharynx. As the function of swallowing is the safe delivery of a food bolus into
the stomach, then the immediate complication of dysphagia is food entering the airway.
Dysphagia in this context is not a subjective symptom and it does not normally refer to any
esophageal abnormality.5
 Numerous studies have tried to establish the incidence of dysphagia after stroke with
figures ranging from 23%. Dysphagia affects up to half of acute stroke patients and carries a
threefold to sevenfold increased risk of aspiration pneumonia. With the subsequent mortality
associated with pneumonia, dysphagia has been recognized as an independent predictor of
mortality after stroke. Fortunately, most patients will make a functional recovery over a period of
days to weeks.5
Exercising swallowing muscles is the best way to improve ability to swallow.
Here, some different exercises developed by dysphagia rehabilitation experts, that include :

Shaker Exercise, Hyoid Lift Maneuver, Mendelsohn Maneuver, Effortful Swallow, Supraglottic
swallow, Super Supraglottic Swallow Maneuver.6

6.2.NEED FOR STUDY

Dysphagia, like any chronic health condition, negatively impacts quality of life (QOL).
Individuals with dysphagia report social and psychological problems associated with having a
swallowing disorder. Healthcare professionals may have different perceptions of an individual's
needs related to swallowing and may not consider or assess the nonphysical aspects of the
disease. This may lead to dissatisfaction with healthcare. Professionals can address the
psychosocial as well as physical aspects of dysphagia by determining individuals' perspective of
their needs. Careful evaluation by the speech-language pathologist and other members of the
dysphagia team with recommendations and a treatment plan formed jointly with the individual is
recommended. Providing education about signs of dysphagia and changes in swallowing due to a
disease process or treatment may improve QOL.7
This incidence and remarkable recovery rate may be accounted for by the bilateral
distribution of control of swallowing musculature in the motor cortex. After hemispheric stroke,
neuroplastic adaptation permits the control of swallowing musculature to be reorganised to the
unaffected hemisphere
According to WHO, stroke kills 17 million people a year, which is almost one
third of all deaths globally. By 2020 stroke will become the leading cause of both death and
disability in the world wide, with the number of fatalities projected to increase to over 20 million
a year and by 2030 to over 24 million a year.2
 Stroke is the third leading cause of death in the world. The prevalence of
stroke in 2008 was 6,500,000. On average every 40 sec someone in the world has stroke.Stroke
is the third leading cause of death in the United States. Over 143,579 people die each year from
stroke in the United States. Each year, about 795,000 people suffer a stroke. About 600,000 of
these are first attacks, and 185,000 are recurrent attacks 3 .In 2008, stroke accounts for 7% of all
deaths -15,409 Canadians. Every 7 minutes a Canadians dies of stroke or cardiovascular disease.
Stroke is Australia’s second greatest killer disease and a leading cause of disability .In 2010,
Australians will suffer around 60,000 new and recurrent stroke. That is one stroke in every 10
minutes4.
In India, the prevalence of stroke is estimated as, 18,012,222 and the population
estimated used is 1,06,570,6075. Recent studies showed that the age-adjusted annual incidence
rate of stroke was 105/100,000 in the urban community of Kolkata and 262/100,000 in a rural
community of Bengal6. In Keralathe annual incidence rate of stroke is180/100,000 population7.
In Karnataka, the prevalence rates per 100,000 Population of cerebro -vascular accident
is 150. In Bangalore, the incidence rate of stroke in urban and rual population is 2009-
102/100,000.7
Dysphagia is a common symptom in stroke patients, and malnutrition is prevalent among
these patients. Thus far, nutritional effects of dysphagic treatment have not been evaluated. The
aim of the present report was to study the effects of swallowing techniques on nutritional and
anthropometric variables. A survey with follow-up was performed at the Departments of
Geriatric Medicine and Neurology, Malmö University Hospital, Sweden. Thirty-eight stroke
patients, 53–89 years of age, with subjective complaints of dysphagia and oral/pharyngeal
dysfunction according to videofluoroscopic barium swallowing examination (VSBE), were given
swallowing treatment. The treatment included oral motor exercise, different swallowing
techniques, positioning, and diet modification. Plasma protein levels, body composition, VSBE,
and a viso-analogical scale for subjective complaints were repeated before and after treatment.
At baseline, 94% of cases had signs of penetration and 50–72% had plasma protein levels below
recommended levels. Treatment reduced the degree of oral dysfunction, (dissociation) and
pharyngeal dysfunction (penetration and constrictor paresis). Sixty percent of cases showed an
improved overall VSBE score, and improved levels of albumin and total iron-binding capacity
were restricted to this group. In cases with unchanged or decreased VSBE score, body weight
was reduced and a negative correlation to total iron-binding capacity was noted (r=−0.60, p <
0.05). Changes of subjective complaints did not correlate with swallowing function or nutritional
improvements. Swallowing treatment improves swallowing function, and improved swallowing
function is associated with improvements in nutritional parameters.8
Several studies concludes that between 300,000 &600,000 individuals in U.S. are affected by
neurogenic dysphagia in each year.Studies on the prevalence of dysphagia range from 25% to
75% in patients who have experienced stroke. There is a consistently high incidence of
dysphagia in patients with stroke.9
Hence the investigator felt that there is a high incidence of dysphagia and there exists
need for swallowing exercises for dysphasia and staff nurses plays a major role in taking care of
stroke patients with dysphasia. Thus researcher opted to assess the effectiveness of structured
teaching programme on swallowing exercises for staff nurses taking care of stroke patients.

6.3.REVIEW OF LITERATURE:-

The review of literature is organized as follows:

Section(a): Reviews related to dysphagia among stroke patients.

Section(b):Reviews related to dysphagia rehabilitation/ treatment.

Section(c): Reviews related to effectiveness of exercises on dysphagia.

Section(d): Reviews related knowledge of staff nurses on swallowing exercises.

Section(a):reviews related to dysphagia among stroke patients:-

A study was conducted to assess the frequency and natural history of swallowing
problems following an acute stroke, 121 consecutive patients admitted within 24 hours of the
onset of their stroke were studied prospectively. The ability to swallow was assessed repeatedly
by a physician, a speech and language therapist, and by videofluoroscopy. Clinically 51%
(61/121) of patients were assessed as being at risk of aspiration on admission. Many swallowing
problems resolved over the first 7 days, through 28/110 (27%) were still considered at risk by the
physician. Over a 6-month period, most problems had resolved, but some patients had persistent
difficulties (6, 8%), and a few (2, 3% at 6 months) had developed swallowing problems. Ninety-
five patients underwent videofluoroscopic examination within a median time of 2 days; 21 (22%)
were aspirating. At 1 month a repeat examination showed that 12 (15%) were aspirating. Only 4
of these were persistent; the remaining 8 had not been previously identified. This study has
confirmed that swallowing problems following acute stroke are common, and it has been
documented that the dysphagia may persist, recur in some patients, or develop in others later in
the history of their stroke.10
A study was conducted with an objective to investigate swallowing laterality in
hemiplegic patients with stroke and recovery of dysphagia according to the laterality.The sample
was comprised of 46 dysphagic patients with hemiplegia after their first stroke. The sample's
videofluoroscopic swallowing study (VFSS) was reviewed. Swallowing laterality was
determined by the anterior-posterior view of VFSS. We measured width difference of barium
sulfate liquid flow in the pharyngoesophageal segment. If there was double or more the width of
that from the opposite width in the pharyngoesophageal segment more than twice on three trials
of swallowing, then it was judged as having laterality. Subjects were assigned to no laterality
(NL), laterality that is ipsilateral to hemiplegic side (LI), and laterality that is contralateral to
hemiplegic side (LC) groups. Measured the following: prevalence of aspiration, the 8-point
penetration-aspiration scale, and the functional dysphagia scale of the subjects at baseline and
follow up.Laterality was observed in 45.7% of all patients. Among them, 52.4% were in the
hemiplegic direction. There was no significant difference between groups at baseline in all
measurements. When compared the changes in all measurements on follow-up study, there were
no significant differences between groups.Through this study, they found that there was no
significant relation between swallowing laterality and the severity or prognosis of swallowing
difficulty. More studies for swallowing laterality on stroke patients will be needed.11

Section(b):Reviews related to dysphagia rehabilitation/ treatment:-

An experimental study was conducted with an objective to examine the effects of a

bedside exercise program on the recovery of swallowing after a stroke. Fifty stroke patients with
dysphagia (<6 months post-stroke) were enrolled and classified into two groups, the
experimental (25 subjects) and control groups (25 subjects). The control group was treated with
conventional swallowing therapy. The experimental group received additional bedside exercise
training, which consisted of oral, pharyngeal, laryngeal, and respiratory exercises, 1 hour per day
for 2 months, and they were instructed regarding this program through the nursing intervention.
All patients were assessed for their swallowing function by Videofluoroscopic Swallowing Study
(VFSS), using the New VFSS scale, the level of functional oral intake, the frequency of
dysphagia complications, the presence (or not) of tube feeding, the mood state and quality of life
before the treatment and at 2 months after the treatment. After 2 months of treatment, the
experimental group showed a significant improvement in the swallowing function at the oral
phase in the New VFSS Scale than that of the control group (p<0.05). Further, they also showed
less depressive mood and better quality of life than the control group. Bedside exercise program
showed an improvement of swallowing function and exhibited a positive secondary effect, such
as mood state and quality of life, on subacute stroke patients with dysphagia. For improvement
of rehabilitation results on subacute stroke patients with dysphagia, this study suggests that
additional intensive bedside exercise would be necessary.12

A study was conducted to examine whether kinematic analysis of laryngeal movements

(which are closely linked to pharyngeal swallowing) can differentiate between normal and
disturbed swallowing, they used a three-dimensional ultrasound movement recording system to
measure the movements of the larynx during swallowing in 32 patients with neurogenic
dysphagia caused by central nervous system lesions and in 32 age- and sex-matched healthy
individuals. At the beginning of an inpatient rehabilitation swallowing program, laryngeal
movements in 24 patients were highly disturbed in terms of velocity curve irregularities. After
rehabilitation, the majority of patients with hitherto irregular velocity profiles exhibited laryngeal
kinematics that were indistinguishable from those of 32 healthy subjects. Kinematic analysis of
laryngeal movements, therefore, is suitable for monitoring motor recovery of swallowing
disturbances in patients with neurogenic dysphagia while undergoing swallowing rehabilitation.13
Section(c): Reviews related to effectiveness of exercises on dysphagia:-

A prospective study using a crossover design was conducted to determine whether

intensive use of the Mendelsohn maneuver in patients post stroke could alter swallow physiology
when used as a rehabilitative exercise.Eighteen outpatients between 6 weeks and 22 months post
stroke were enrolled in this study to compare 2 weeks of treatment with 2 weeks of no treatment.
Each participant received an initial videofluoroscopic swallow study (VFSS) and an additional
VFSS at the end of each week for 1 month for a total of 5 studies. During treatment weeks,
participants received 2 treatment sessions per day performing Mendelsohn maneuvers with
surface electromyography for biofeedback. Measures of swallowing duration,
penetration/aspiration, residue, and dysphagia severity were analyzed from VFSS to compare
treatment and no-treatment weeks. Significant changes occurred for measures of the duration of
superior and anterior hyoid movement after 2 weeks of treatment. Improvements were observed
for duration of opening of the upper esophageal sphincter (UES), but results were not statistically
significant. Measures of penetration/aspiration, residue, and dysphagia severity improved
throughout the study, but no differences were observed between treatment and no-treatment
weeks. Intensive use of the Mendselsohn maneuver in isolation altered duration of hyoid
movement and UES opening in this exploratory study. Results can guide future research toward
improved selection criteria and exploration of outcomes. Larger numbers of participants and
variations in treatment duration and intensity will be necessary to determine the true clinical
value of this treatment.14

A study was conducted to examine the timing of physiological swallowing events in

patients before and after completion of an exercise-based dysphagia intervention (McNeill
Dysphagia Therapy Program; MDTP) and compared their performance to that of healthy
volunteers.Eight adults (mean age, 57.5 years) with chronic dysphagia (mean, 45 months)
completed 3 weeks of the MDTP. Before and after the MDTP we measured lingual-palatal and
pharyngeal manometric pressures during swallows of thin liquid, thick liquid, and pudding
material in 5-mL volumes. Using the pressure peak of the pharyngoesophageal segment clearing
wave as the anchor point, we measured the relative timing of pressure peaks from the anterior,
middle, and posterior parts of the tongue and the manometric peaks from the base of the tongue,
the hypopharynx, and the nadir of the pharyngoesophageal segment. The results are then
compared with the identical measures obtained from 34 healthy adults (mean age, 44.0 years).
The timing of physiological events before the MDTP was significantly slower than that of the
group of healthy volunteers. The timing data from after the MDTP were not significantly
different from those of the healthy group. The magnitude change was greatest for thin liquid.
Dysphagia therapy with the MDTP improves the timing of physiological events during
swallowing. Temporal coordination of swallowing components after therapy approximates that
of healthy adults, suggesting a normalization of swallow timing after the MDTP.15
 An experimental study was conducted to investigate functional and physiological
changes in swallowing performance of adults with chronic dysphagia after an exercise-based
dysphagia therapy.Intervention study: before-after trial with 3-month follow-up evaluation in an
outpatient clinic within a tertiary care academic health science center. Adults (N=9) with chronic
(>12 mo) dysphagia after unsuccessful prior therapies. Subjects were identified from among
patients referred to an outpatient dysphagia clinic. Subjects had dysphagia secondary to prior
treatment for head/neck cancer or from neurologic injury. All subjects demonstrated clinical and
fluoroscopic evidence of oropharyngeal dysphagia. No subject withdrew during the course of
this study. All subjects completed 3 weeks of an intensive, exercise-based dysphagia therapy.
Therapy was conducted daily for 1h/d, with additional activities completed by subjects each
night between therapy sessions. Primary outcomes were clinical and functional change in
swallowing performance with maintenance at 3 months after intervention. Secondary,
exploratory outcomes included physiological change in swallow performance measured by
hyolaryngeal elevation, lingual-palatal and pharyngeal manometric pressure, and surface
electromyographic amplitude. Clinical and functional swallowing performances improved
significantly and were maintained at the 3-month follow-up examination. Subject perspective
(visual analog scale) on functional swallowing also improved. Four of 7 subjects who were
initially feeding tube dependent progressed to total oral intake after 3 weeks of intervention.
Physiological indices demonstrated increased swallowing effort after intervention.Significant
clinical and functional improvement in swallowing performance followed a time-limited (3 wk)
exercise-based intervention in a sample of subjects with chronic dysphagia. Physiological
changes after therapy implicate improved neuromuscular functioning within the swallow
mechanism.16

A Prospective cohort intervention study was conducted with an objective to examine the
effects of lingual exercise in stroke patients with dysphagia, with 4- and 8-week follow-ups at
Dysphagia clinic, tertiary care center. Ten stroke patients (n=6, acute: ≤3mo poststroke; n=4,
chronic: >3mo poststroke), age 51 to 90 years (mean, 69.7y). Subjects performed an 8-week
isometric lingual exercise program by compressing an air-filled bulb between the tongue and the
hard palate. Isometric and swallowing lingual pressures, bolus flow parameters, diet, and a
dysphagia-specific quality of life questionnaire were collected at baseline, week 4, and week 8.
Three of the 10 subjects underwent magnetic resonance imaging at each time interval to measure
lingual volume. All subjects significantly increased isometric and swallowing pressures. Airway
invasion was reduced for liquids. Two subjects increased lingual volume. The findings indicate
that lingual exercise enables acute and chronic dysphagic stroke patients to increase lingual
strength with associated improvements in swallowing pressures, airway protection, and lingual
volume.17

Section(d): Reviews related knowledge of staff nurses on swallowing exercises:-

An experimental study was conducted to investigate the frequency of aspiration

pneumonia in conscious stroke patients fed by a family member and examined the effect of
introducing training in swallowing techniques by nurses. A total of 96 consecutive patients
presenting with dysphagia due to acute stroke were included in the study. Patients presenting
between January 2000 and July 2003 (n = 48) were fed orally by a family member given general
nursing information (group A), whereas those presenting between August 2003 and March 2005
(n = 48) were fed orally by an experienced nurse trained in specific swallowing techniques
(group B). All patients were examined daily for the presence of aspiration pneumonia. The
incidence of aspiration pneumonia was 33.3% in group A and 6.3% in group B (P < 0.05). The
incidence of aspiration pneumonia in dysphagic stroke patients who are orally fed is still high.
Training in swallowing during oral feeding offers clear protection against pneumonia in
conscious stroke patients.18

A quasi-experimental parallel cluster design was conducted with the aim to examine the
functional swallowing and nutritional outcomes of swallowing training in institutionalized stroke
residents with dysphagia. Seven institutions with similar bed sizes were selected. All subjects in
the experimental group received a structured swallowing training programme. The subjects in the
experimental group (n = 40) received 30 minutes of swallowing training each day for 6 days per
week for 8 weeks. The control group (n = 21) did not receive any training.  After swallowing
training, mean differences in volume per second, volume per swallow, mid-arm circumference
and body weight between pre- and post-training of the experimental group were significantly
higher than for the control group, while mean differences in neurological examination and
choking frequency during meals for the experimental group were significantly lower than in the
control group. This study used objective timed swallowing tests, a swallowing questionnaire, and
a neurological examination to evaluate the effects of swallowing training. However,
videofluroscopy is generally considered the best method for evaluating the pharyngeal and
esophageal stages of swallowing, and introducing this technique is recommended for future
studies. Furthermore, it is recommended that nursing professionals should conduct swallowing
training protocols in stroke patients to help prevent aspiration from dysphagia.19

6.4. STATEMENT OF THE STUDY:-

A study to assess the effectiveness of structured teaching programme on swallowing

exercises for dysphagia among staffnurses in selected hospitals Bangalore.
6.5. OBJECTIVES OF THE STUDY:-

 To assess the pre-test level of knowledge on swallowing exercises for dysphagia among
staff nurse.
 To find the effectiveness of structured teaching programme on swallowing exercises for
dysphagia among staff nurses.
 To determine the association between pre-test level of knowledge and skill regarding
swallowing exercises and selected demographic variables of staff nurses.

6.6. OPERATIONAL DEFINITIONS:-

Assess:-
In this study assess is an activity to decide the level of knowledge and skill on
swallowing exercises for dysphagia among staff nurses with the help of structured knowledge
questionnaire and checklist

Effectiveness:-
 It refers to a significant improvement in knowledge and skill of staff nurses on
swallowing exercises for dysphagia as determined by difference between pre-test and post-test
knowledge scores.

Structured teaching programme:-

It refers to systematically organized teaching programme prepared by the investigator to
educate the staff nurses on dysphagia and swallowing exercises by using lecture cum discussion
method.

Swallowing exercises:-
In this study it refers,the set of exercises provided to strengthen the muscles involved in
swallowing.
Dysphagia:-
In this study it refers to difficulty in swallowing experienced by stroke patients.
Staff nurses:-
Refers to registered nursing personnel working in the hospital .

6.7. HYPOTHESIS:-
H1: There will be significant gain in the post-test knowledge and skill score of staff nurses
on swallowing exercises for dysphagia after attending STP as compared to the pre-test scores.
H2 : There will be significant association between the pre-test level of knowledge and skill on
swallowing exercise and the selected demographic variables of staff nurses.

6.8. ASSUMPTIONS:-
1. Staff nurses may have some knowledge regarding swallowing exercises.
2. Nurses may be willing to improve their knowledge and learn the skills regarding
swallowing exercises for dysphagia.
3. STP may help staff nurses to promote their knowledge and skill on swallowing exercises
for dysphagia.
 4. Staff nurses may utilize this knowledge and skill during their practice to improve
swallowing ability of dysphagia patients.

6.9. DELIMITATIONS:-
The study is delimited to
 40 staff nurses working in Selected hospitals, Bangalore.
 Staff nurses who are present at that time of study.
 Effectiveness of STP in terms of knowledge and skill scores only.
 One month period of data collection.
7. MATERIALS & METHOD OF STUDY:-
7.1. SOURCES OF DATA:-
Data will be collected from staff nurses in selected hospitals ,Bangalore.
7.2. METHOD OF DATA COLLECTION:-
7.2.1. TYPE OF STUDY/RESEARCH APPROACH:-
Evaluative approach/Quantitative approach.
7.2.2. RESEARCH DESIGN:-
Pre-experimental, one group pre-test, post-test design.
7.2.3. VARIABLES:-
Independent variable:
Structured teaching programme on swallowing exercises for dysphagia.
Dependent variable:
Knowledge& skill of staff nurses regarding swallowing exercises for dysphagia.
7.2.4. SAMPLING TECHNIQUE:-
Purposive sampling technique.
7.2.5. SAMPLE & SAMPLE SIZE:-
Sample consists of 40staff nurses, from selected hospitals, Bangalore.

7.2.6. SELECTION CRITERIA:-

Inclusion criteria:-
Staff nurses who are
 Working in neuro& general medical wards.
  Willing to participate.
vailable at the time of study.
Exclusion criteria:-
 Staff nurses who have undergone previous training programme on
swallowing exercises.

7.2.7. DURATION OF THE STUDY:-

One month period of data collection.
7.2.8. TOOL OR INSTRUMENT:-
SECTION:A:- Sociodemographic profile.
SECTION:B:- Structured knowledge questionnaire on swallowing exercises
7.2.9. DATA COLLECTION PROCEDURE:-
A formal permission will be obtained from the authorities of hospitals and a
written consent will be taken from the participants after explaining the purpose of the study. Pre-
test will be conducted by using structured knowledge questionnaire to assess the knowledge and
check list will be used to assess skill of the staff nurses on swallowing exercises and followed by
structured teaching programme will be conducted and on 7th day post-test will be conducted by
using the same structured knowledge questionnaire and check list.

7.2.10. PLAN FOR STATISTICAL ANALYSIS:-

The data obtained will be tabulated and analyzed in terms of the objectives of the study by
using descriptive and inferential statistics.
The plan of data analysis is:
Descriptive statistics:
 Frequency and percentage distribution will be used to analyze the socio-
demographic variable.
 Mean, mean percentage and standard deviation will be used to assess the
pre-test and post-test knowledge & skill score of staff nurses.
Inferential statistics:
 Paired t test will be used to assess the effectiveness of STP on
swallowing exercises for dysphagia.
 Chi-square test will be used to find out the association between pre-test
level of knowledge& skill on swallowing exercises and their selected
demographic variables of staff nurses.

7.3. DOES THIS STUDY REQUIRE ANY INVESTIGATION TO BE CONDUCTED ON

PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE
BRIEFLY:
Yes, Structured knowledge questionnare& check list will be administered once after and before
7 days of STP as an intervention to impart knowledge on swallowing exercises among staff
nurses.

7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION

INCASE OF ?

Yes, informed consent will be obtained from respective authorities and staff nurses.
Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study will be
maintained with honesty and impartiality.

8. REFERENCES:

1. Eating. Wikipedia. available from URL en.wikipedia.org/wiki/eating

2. Dysphagia. Wikipedia. available from URL en.wikipedia.org/wiki/dysphagia

3. Joyce. M. Black Text book of medical and Surgical Nursing 7th edition volume – I
Elsevier publication 2004 – P 4 – 5
4. WHO. annual report on prevalence and incidence of stroke.
5. Brunner and Siddhartha. Text book of medical surgical nursing. 11th edition. J.B
.Lippincott Company. 2007. Page No: 705-720.

6. Das S.K. A Prospective Community-Based Study of Stroke in Kolkata 2009.

7. Lippincott Williams & Wilkins. quality of life issues related to dysphagia. journal of
advanced nursing. Volume 44. Issue 5. pages 469–478.

8. SölveElmståhl. Treatment of dysphagia improves nutritional conditions in stroke patients.

Journal dysphagia volume 14. Issue 2. pp 61-66
9. Communication Facts: special populations: dysphagia. Available from:
URL:http://www.asha.org/research/reports/dysphagia/.
10. SmithardDG. thenatural history of dysphagia following stroke. Available from:
URL:http:// www.ncbi.nlm.nih.gov/pubmedhealth/PMH9294937/
11. Kim MS. the influence of laterality of pharyngeal bolus passage on dysphagia in
hemiplegic patients. Available from: URL:http://
www.ncbi.nlm.nih.gov/pubmedhealth/PMH23185735/

12. Kang JH. effect of bedside exercise on swallowing exercise after stroke. Available from
URL http://www.ncbi.nlm.nih.gov/23185735

13. A.D.A.M. Medical Encyclopedia. Stroke[on line].2011 Jun 24(cited 2011 Nov(12);
Available from: URL:http:// www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001740/
14. Kangnaowan Pellet.swallow physiology when used as a rehabilitative exercise. Available
from: URL:http:// www.ncbi.nlm.nih.gov/pubmedhealth/PMH22977777/
15. Koenig KL. Whyte EM. Munin MC. O’Donnell L. Skidmore ER. Penrod LE Lenze EJ.
Stroke related knowledge and health behaviors among post stroke patients in inpatient
rehabilitation. Arch phys Med Rehabil 2007; 88(9):1214-6.
16. Burton CR. functional and physiological changes in swallowing. Available from:
URL:http:// www.ncbi.nlm.nih.gov/pubmedhealth/PMH22365489/.
17. RobbinsJA. The Effects of Lingual Exercise in Stroke Patients With Dysphagia
http://www.sciencedirect.com/science/article/pii/S000399930601457.
18. .Gouri Devi M. Rao VN. Prakashi R. Stroke prevalence in rural population of
Karnataka2010.
19.Judith A Stewart. R Dundas. R S Howard. A G Rudd and C D A Wolfe. Ethnic
differences in incidence of stroke: prospective study with stroke register[on line].1999.
Apr10(cited2011Nov(12);
Availablefrom:URL:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27822/.
9. SIGNATURE OF CANDIDATE

10. REMARKS OF GUIDE

11.1 NAME AND DESIGNATION OF GUIDE Mrs. Jayasree madam

Head of the department

Medical Surgical Nursing

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT Mrs. Jayasree madam

 Head of the department

Medical Surgical Nursing

11.6 SIGNATURE

12.1 REMARKS OF PRINCIPAL

12.2 SIGNATURE