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RAJIV GANDHI UNVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1.

NAME OF THE CANDIDATE E.T.C.M. COLLEGE OF NURSING AND ADDRESS KOLAR-563101, KARNATAKA. 2. NAME OF INSTITUTION KOLAR. 3. COURSE OF STUDY AND OBSTETRICS & GYNECOLOGICAL THE SUBJECT NURSING. 4. DATE OF ADMISSION TO 01-06-2010 COURSE 5. A STUDY TO ASSESS THE EFFECTIVENESS OF INFORMATION BOOKLET ON PREGNANCY INDUCED TITLE OF THE TOPIC: HYPERTENSION AND ITS SELF CARE MANAGEMENT AMONG THE MOTHERS WITH PREGNANCY INDUCED HYPERTENSION IN SELECTED HOSPITAL AT KOLAR. M.SC (NURSING) E.T.C.M. COLLEGE OF NURSING, MRS. SRIDEVI ANNAPURNA. P 1st YEAR M.SC NURSING

6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION Expecting a baby is definitely one of the most joyful experiences in a womans life. The childbirth for a mother is an important contribution to the

motherhood and is a highly personal and individual experience. Journey in life is equally important as arriving at the destination. The journey towards giving childbirth may be a long and painful experience but the result is very sweet1. Pregnancy induced hypertension (PHI) occurs more frequently in young prime gravid. It is more common in the mothers over 35years of age and multiple pregnancies with diabetes and obese mothers. It is equally common in women, from low socio-economic group who are not likely to have received adequate antenatal care. Pregnancy induced hypertension is characterized by hypertensions and proteinuria accompanied by oedema. It develops only during pregnancy. Both mother and fetus are adversely affected by maternal hypertension2. Pregnancy induced hypertension is recognized as the death in which requires the united efforts of all members of the health care team in close collaboration with other medical personnel. Incidence of Eclampsia is approximately 1 in 1500

pregnancies. Of this about 50% occurs in the antenatal period, 30% occurs during the intra partum period and 20% takes place within the first few hours after delivery. Deaths due to eclampsia occur because of cerebral haemorrhage and adult respiratory distress syndrome. Maternal mortality due to eclampsia varies between 2-30% and is much higher in rural areas.PIH especially pre eclmpsia is a major cause of maternal and peri natal morbidity and mortality worldwide45. The impact of pregnancy induced hypertension on birth outcomes has been extensively studied. However, the potential long term effect of pregnancy induced

hypertension on infants. Pregnancy induced hypertension has been confirmed to increase significantly the risk of low birth weight by both increasing preterm birth as well as reducing fatal growth. In India the national incidence of pregnancy induced hypertension is 15.2% with the incidence in nulliparous women being four times greater than in multipart women. In Asia, the number of maternal deaths is estimated to have dropped from 315,000 to 139,000 between 1990-2008. The report, Trends in maternal mortality by the WHO, the UNICEF, the united nation population fund (UNFPA) and the World Bank. Worldwide and substation cause and peri natal mortality and morbidity. Women with pre eclampsia are 2-3 times more likely to have caesarean delivery compared to normotensive women and have longer hospital stay. The combined prevalence of various hypertensive disorders in pregnancy is said to be 6-8%, which are the leading causes of maternal and peri natal mortality and morbidity.47

NEED FOR THE STUDY Hypertensive disorder of the pregnancy are leading cause of maternal and infant mortality and morbidity, world wide it has been estimated that approximate 50,000 women die every year from eclampsia. According to world health organization ( WHO) it has been estimates, hypertensive disorder of pregnancy affect 5-10% of all pregnancies, 1.5% deaths per 1,00,000 live birth due to pre Eclampsia or eclampsia were reposted from U.S.A. As per the British Eclampsia survey (BES) mortality, from eclampsia was found to be approximately 2%. However worldwide picture remains poor.38 In Europe in the early 20Century maternal mortality was over 20%, similar to that of in Bangladesh. Conducted an epidemiological investigation of PIH, INA

population of 3.7 million in china. The incidence of PIH was 9.4% that of mild, moderate pregnancy induced hypertension, pre eclampsia, eclampsia 23%, chronic hypertension with PIH were 4.7 %2.6 %1.7 %and 0.2%respectively. The maternal and prenatal mortality of PIH groups were significantly higher than that of group without PIH. The result reveals that pathogenesis of pregnancy induced hypertension was positively related age, prime gravida, multiple pregnancy, labour, posture intensity, maternal education level, body status, hereditary and various complications during pregnancy.40 Maternal and child health programme is poorly utilized by pregnant women, only 49.29% of the total pregnant women receive antenatal checkups from health professionals, only two of the pregnant women were visited by the health workers. Caring of primi gravid with eclampsia is a challenge to any mid wife keeps observation, promote decision making ability to use life saving procedures and referral to the right place, at the right time, can save the mother and the baby. The mother requires intensive care with continuous monitoring and recording the baby also need close observation and care for the first 24-48 hours in the neonatal intensive care unit.32 Pregnancy induced hypertension and toxaemias are the top rankers of the maternal mortality which can be reduced with enhanced mothers education and availing of optimum antennal care is essential. In the light of the above facts and from experienced of the investigator, of was found essential to assess the knowledge of the mothers on PIH and their self care activities to prevent possible complications and thereby reduce maternal mortality and morbidity. Women through their intervention thus promote safe child birth experience as a memorable and pleasant one contributing to healthy mother and child to the society.

A Pilot study was conducted by ICMR in five states namely Uttar Pradesh. Maharashtra, Karnataka, Uttaranchal and Delhi and published in July 2003. These states were selected representing high MMR, medium and low MMR states. The main cause of death was observed to be PPH (17%) post partum septicaemia (13%), PIH or eclamspia (15%) and anaemia 13%. About 70% deaths in postnatal period and 24% of antenatal period and 7% were found to be during delivery.34 The one year census of district hospitals centre show that nearly 360-400 pregnancy induced hypertension mothers in kolar district. The national health Policy aimed at reducing the maternal mortality in India from the more than 400 per 100,000 live births to less than 200 per 100,000 live births by the end of year 2000 but failed. The millennium Development Goals had set the target of achieving 200 maternal deaths per lakh of live births by 2007 and 109 per lakh of live births by 2015. We are far from that till date34 Based on the above review literature and researcher experiences the interventions during pregnancy may improve maternal outcomes. In this regard the intervention includes primary prevention detection of increased risk and early detection of any stage of pregnancy induced hypertension. Secondary prevention of progression is by treatment at primary level or referral for expert care. 6.2 REVIEW OF LITERATURE Review of literature is task of reviewing literature which involves the identification analysis and reporting of existing information on the topic of interest. I t provides the bases to locate the data mew ideas that need to be included in the present study it helps the researcher selection critical Review of literature is the task of reviewing literature which involves to find the accurate data that could be used for supporting the present finding and drawing conclusion.

Review of literature for the present study has been organized under the following heading. 1. Review of literature related to pregnancy induced hypertension. 2. Review of literature related to effectiveness of information booklet. 3. Review of literature related to life style and pregnancy induced hypertension.

1. Review of literature related to pregnancy induced hypertension: A study was conducted on 72 pregnant women (out of 106) with eclampsia who satisfied the inclusion and exclusion criteria in the year (2009). All subjects were cases of ante partum and intra partum eclampisa with a gestational age of more than 28 weeks. The incidence of eclampsia observed in this study 2.17%. The peri natal deaths were more in the ante partum type of eclampsia, gestational age was less than 32weeks. The peri natal deaths also increasing during preterm, vaginal delivery of low birth babies13. A study was conducted on prevention of pre-eclampsia have been evaluated in randomized trials. This evidence provides the basis for a rational approach to care. Overall, there is insufficient evidence for any firm conclusion about the effects of any aspect of diet or lifestyle during pregnancy. Anti platelet agents are associated with a 19% reduction in the risk of pre-eclampsia (95%), a 7% reduction in the risk of preterm birth, a 16% reduction in the risk of stillbirth or neonatal death and an 8% reduction in the risk of a small for gestational age baby. For mild to moderate hypertension, trials evaluating bed rest are too small for reliable conclusions about the potential benefits and hazards.28

A study was conducted on life style among all PIH mothers study subjects in the second quartile of seasonal average lead level at conception was 1.07 (95% CI: 1.05-1.08), and odds ratios in the third and fourth quartiles were 1.22 (95% CI: 1.201.25) and 1.16 (95% CI: 1.15-1.18), respectively. The odds ratios for the second, third, and fourth quartiles of seasonal average lead level at birth were 1.07 %, 1.21% , and 1.24%, respectively. The risk of PIH increased by 4% per 0.05 micro g/m3 increase in seasonal average lead level at conception and birth, in both smokers and non smokers. These results suggest that higher environmental lead levels increase the risk of PIH19. Pregnancy induced hypertension occur more frequently in young primi gravid mothers. Its more common in mothers over 35 years o f age and multiple pregnancy with diabetes and obese mothers. It is equally common in women, from low socioeconomic group who are not likely to have received adequate antenatal care. PIH is characterized by hypertension and proteinuria accompanied by edema. It develops only during pregnancy. Both mother and foetus are adversely affected by maternal hypertension. PIH is recognized as the death in which requires the untied efforts of all members of the health care team in close collaboration with other medical personnel.20 A quasi experimental study was conducted on effectiveness of self instructional module on self care activities of pregnancy induced hypertension in terms of maternal outcome among 70 primigravida women with PIH, attending OPD of selected hospitals in kolar. Non probability purposive sampling was used and the tool used was structured interview schedule. The interrelated reliability was tested and the value was 0.87%. It was concluded that self instructional module was effective in

imparting the knowledge and practice of self care activities and also in the effective control of PIH among primigravida with PIH.24 A descriptive study was to identify the factors associated with PIH among 277 antenatal women, who developed PIH in Netherlands. It was found that 53.3% of antenatal women had low protein, rich carbohydrate and extra salt in their diet. The current practice follows a regular diet with moderate sodium intake of 2-3gm/day with light use of salt for taste. Limiting beyond this use is contrary to physiologic need in pregnancy27. An experimental study was conducted on calcium supplementation in pregnancy to prevent PIH among laboratory and clinical trial in Quezon City, Philippines. Findings showed that lowering of blood pressure and prevention of PIH is seen in those, who received calcium supplementation.22 A descriptive study was conducted on among antenatal mothers to assess the knowledge regarding the control of PIH at the SAT Hospital Trivandrum. The tool used for the study was interview schedule and used analysis was chi-square, frequency percentage. She concluded that the knowledge level of antenatal mothers, regarding PIH and its control measures, were highly inadequate.33

2. Review of literature related to effectiveness of information booklet: An experimental study was conducted to evaluate the self care instructional booklet on pre eclampsia and its self care management developed on the basic of identified learning need of mother with pregnancy induced hypertension in selected hospital of Kerala. A purposive sampling technique was used to select the sample from the study population. The tool used was structured interview schedule

and opinionaire. The difference between pre test and post test knowledge scores of PIH mothers on pre eclampsia and its self care management was significant at 0.05 level and 0.01 level (value 43.43) She concluded the before information booklet the knowledge of primigravida women with PIH was inadequate the information booklet on selected self care activities considerably enhanced the knowledge of primigravida women with PIH to practice selected self care activities. The practice of SSCA by the primigaravida women with PIH attain favourable maternal out come. Conclusion drawn from the knowledge and practice of SSCA among primigravida women with PIH.18 A study was conducted on effectiveness of practice of anti hypertensive therapy information booklet is effects of aspirin in pregnant women with chronic hypertension, although several trials had subset data on such women. The doubleblind place be controlled trial designed specifically to assess aspirin effects in chronic hypertension involved 774 women. Low-dose aspirin, 60 mg daily, begun before 26 weeks gestational age, it significantly reduce preeclampsia, intrauterine growth retardation, and peri natal mortality or significantly increase abruption, postpartum haemorrhage, and neonatal intra ventricular hemorrhage.29 A study was conducted on effectiveness of planned health education through information booklet on health practice of cancer patient s regarding management of selected side effects of radiation therapy. The overall finding of the study clearly showed that planned health education was significantly effective in improving the knowledge and practice of cancer patients receiving radiation therapy. Regarding effectiveness of planned health education the overall pre test knowledge (29.47%) and 32% is very less when compared with post test knowledge 78.10% and practice 77.50% score. The correlation between knowledge and practice of {post test value

r=0.707} is found byt test is analyzed to find the pre and post test knowledge t=5.57 and practice `t`=4.32 score which is found to be significant at p<0.001 level. The information booklet used for health education helped to update and improve knowledge of cancer patients regarding side effects of radiation therapy, so that can be controlled.29 A study was conducted by Nine wells hospital Dundee UK, with the aim to develop an evidencebased information booklet for patients and relatives after preparing for transfer from intensive care units. This collaborative study used an exploratory design with elements of the action research cycle in three phases, which involved identifying patients and relatives information needs around the time of transfer, designing and developing an information booklet, and the introduction and evaluation of the booklet into practice. Semi structured interviews were used to elicit the views of patients and relatives regarding their information needs. Members of the multidisciplinary teams were involved in identifying and reviewing the booklet content. Evaluation identified positive outcomes relating to patients and relatives satisfaction with written information and enhanced communication with other wards and health care professionals. This study has demonstrated the value of providing patients and relatives with written information regarding transfer from ICUs. Furthermore the study confirmed the feasibility and importance of including patients and relatives in the process of booklet development to ensure that their needs for information are being met.30 Bristol urological institute, South mead Hospital, Bristol UK, conducted a study with the objective to report a scientific approach incorporating patient preferences towards the development of a patient information booklet about ureteric stents. Phases I of the study included 35 adult patients with ureteric stents who were

surveyed using semi structured interviews (4 patients) and a questionnaire (31 patients) to assess various issues relating to information given to patients about ureteric stents. In addition, published papers were assessed and clinician opinions sought. The results formed the basis for a comprehensive patient - information booklet about ureteric stents that incorporated patient views and preferences. In phase 2 the booklet was tested and formally validated by inviting 30 patients, a panel of 20 urologists and general practitioners, and five stent manufacturers to assess the booklet for adequacy, coverage and readability of the content. Out of 35 patients, 30 participated in the initial survey, 80% of patients reported dissatisfaction about the information they received. Patients wanted more information about the use, adverse events and effects of stents on daily life, 85% preferred all relevant information about the stents to be in a written format with illustrative drawings. An eight page booklet was thus developed. The validation study revealed that the booklet matched patients experience and was reported as satisfactory by clinicians and manufacturers. A valid information booklet on ureteric stents was developed, incorporating patients expectations and views. This booklet expected to be an effective tool for patient communication that would help patients cope better with indwelling stents and be useful in counselling patients. A similar approach could be adopted for the development of other patient information packs.31 3. Review of literature related to life style and pregnancy induced hypertension : A cohort study was conducted by Landsbergis et., al among on job psychological stress and PIH among 717 women in California. They examined the association between workers during pregnancy and PIH and concluded that among women in higher status jobs, gestational hypertension was associated with job pressure, and low control of psycho social job stressors22.

A randomized controlled trail was conducted on double bind trail to test and rest in the left lateral position in reducing PIH and pre eclampsia among 174 nor motensive women at 28-29 weeks of gestation. The experimental group, which received treatment protocol was 37 women and other 37 women received standard antenatal control until delivery. The result in the study were that 29(78.32%) women in the control group developed pre-eclampsia as opposed to only 4 (10.8%) cases in the treatment group.21 An experimental study was conducted on 24 hours blood pressure patterns. In physiological pregnancy PIH pre eclampsia and chronic, how among 4 groups of women with singleton pregnancy. 73 centre, 48 patients with PIH, 38 with pre eclampsia toxaemia and 53 with mild to moderate chronic hypertension in New York. It was concluded that standardized 24 hours blood pressure monitoring during pregnancy allows qualitative and quantitative evaluation of the hypertension status13. A retrospective study was conducted on eclampsia, to see the incidence epidemiology, clinical profile of eclampsia patients and the effects of current intervention strategy for eclampsia on maternal and prenatal outcome. Analysis of case recovery of all eclampsia cases from mid April to April 2005. The study was concluded inferring that it appears that current intervention strategy for eclampsia in the maternity hospital is effective in reducing maternal mortality or any morbidity, but peri natal outcome still needs to be improved15.

STATEMENT OF THE PROBLEM: A study to assess the effectiveness of information booklet on pregnancy induced hypertension and its self care management among the mothers with pregnancy induced hypertension in selected hospitals at kolar.

6.3 OBJECTIVES: 1. To assess the level of knowledge of pregnancy induced hypertension mothers regarding pregnancy induced hypertension and self care management. 2. To assess the effectiveness of information booklet on pregnancy induced hypertension by comparative pre and post test knowledge its scores. 3. To find out the association between the demographical variables and the knowledge level of pregnancy induced hypertension mothers.

6.4. OPERATIONAL DEFINITIONS: Effectiveness: In this study its refer to gaining knowledge as determined by significant pre test and post test knowledge scores. Information booklet: Information booklet is a systematically developed about pregnancy induced hypertension and its self care management. It consists of pictures with simple instruction. This was given to mothers with explanation after the pre test. Mothers with pregnancy induced hypertension: Mothers with increased blood pressure of more than 140/90 mmHg as a direct result of pregnancy after 20 weeks of gestation and diagnosed by the Doctor. Self care: The personal care carried out by the pregnant mother.

Knowledge: Responses given by the mother regarding pregnancy induced hypertension and its self care management as to identify with the help of information booklet and questionnaire prepared by the investigator. 6.5. ASSUMPTION: 1. Mothers may not have the sufficient knowledge regarding pregnancy induced hypertension. 2. Participants will co-operate and respond appropriately, to the structured questionnaire. 3. Information booklet is enhance the knowledge of pregnancy induced hypertension mothers regarding pregnancy induced hypertension and its self care management. 4. Information booklet is help to reduced significant maternal and fatal morbidity and mortality. 6.6. HYPOTHESIS: Ho1: There will be significant differences between pretest and post test knowledge regarding pregnancy induced hypertension and its self care management among the mothers with pregnancy induced hypertension. Ho2: There will be significant association between the selected demographic variables and pre test and post test level of knowledge of pregnancy induced hypertension mothers. 6.7. VARIABLES UNDER THE STUDY: Independent variables:

Providing information by information booklet on pregnancy induced hypertension and its self care management. Dependent variables: Knowledge of the mother, regarding the pregnancy induced hypertension. Extraneous variables: It includes the age, religion, education, occupation, family income, family history of hypertension and previous exposure to knowledge on self care management of pregnancy induced hypertension. 7.0. MATERIAL AND METHODS: 7.1. SOURCE OF DATA: Data will be collected from the pregnancy induced hypertension mothers in selected hospitals at kolar. 7.2. RESEARCH APPROACH: Evaluative research approach. 7.2.1 Research Design: Pre experimental research design with one group with pre test and post test. 7.2.2 Setting: The study will be conducted on selected hospitals, at kolar. 7.2.3. Population: For the population study comprises of pregnancy induced hypertension mothers attending outpatient department of selected hospitals, at kolar and are diagnosed as pregnancy induced hypertension during the period of study.

7.2.4. Sampling Technique: Non probability purposive sampling technique. 7.2.5. Sample size: The sample comprises of 40 pregnancy induced hypertension mothers who are fulfil the inclusive criteria attending OPD during the period of data collection. 7.2.6. Sampling criteria: Inclusive criteria: Pregnancy induced hypertensions mothers include who are: Attending the OPD during the period of study. Able to read and understand English or kanada. Willing to participate in the study. More than 20 weeks of gestation. Exclusive criteria: The study excluded patient who are Hospitalized having PIH complications associated with anemia, heart disease and diabetes. Not willing to participate in the study. 7.2.7. DATA COLLECTION TOOL: The instruments used in the study are Demographical variable Performa, learning need assessment tool and information booklet on pregnancy induced hypertension and its self care management. Part 1: Demographical variables included in the Performa are age religion, occupation, family monthly income, family history hypertension and its self care management.

Part 2: learning needs assessment tool. Part 3: Information booklet and its self care management. Part 4: Structure questionnaire to assess the effectiveness of information PIH and its self care management. 7.2.8. METHOD OF DATA COLLECTION: The data will be collected in the followed stages: Ethical consideration:- The written permission from the authorities of the selected nursing institution will be obtained prior to data collection. The study participant will be selected by using Non probability purposive sampling technique. Formal permission will be obtained from study participants after explaining the objectives of study. The antenatal mothers with PIH were selected on the basis of inclusive criteria. Pre test data will be collected by the researcher herself using learning need assessment tool, information of booklet to be provide. Conduct post test one week of giving information booklet on PIH and its self care management and evaluation its effectiveness. 7.2.9. METHOD OF DATA ANALYSIS: Demographic data, level of knowledge, before and after information booklet on PIH and its self care management will be analyze by using descriptive statistics such as mean, percentage, standard deviation.

Data analysis of effectiveness of information booklet on PIH by comparing pre test and post test level of knowledge will be assessed by using inferential statistics as paired t test. Chi-square test will be to find out the association between the demographical variable and pre test and post test assessment level of knowledge.

7.3.

DOES

THE

STUDY

REQUIRE

ANY

INVESTIGATION

OR

INTERVENTION (OR) ANIMALS? No.

TO BE CONDUCTED ON PATIENT OTHER HUMANS

7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM INSTITUTION? 1. Permission will be obtained from the authorities of the selected hospitals. 2. Permission will be obtained from research committee. 3. Informed consent will be obtained from the subject enrolled before the study.

8. LIST OF REFERENCES: 1. Adele politer, et al., Text book for Maternal and child Health Nursing. 4th Edition. Wippincon William. New York. 2002. 404-410 2. Beak M.I and Janson. M. A Text Book of essential Maternity Nursing. 2nd Edition), Philadelphia, Mosby Company. 1992. 510-512. 3. Cunningham, Mac Donald, Gant., et al. Text Book Williams Obstetrics. 19th Edition. USA. 1993. 763-806 4. Dianc M., Fraser, Margaref A. Cooper. Myles Text Book for Midwives. 14th Edition. New York, Churchil Living Stone. 2003. 351-370 5. Dickson, Silverman, Kaplan, .A Text Book for Maternal and infant Nursing care. 3rd Edition, New Delhi, Mosby Printers. 1994. 580-595 6. Dutta D.C. Text Book of Obstetrics,. 4th Edition, Calcutta,. New Central Agency Pvt.Ltd. 2000 241-260 7. Emiles stone Mc Kinnay, Jean Weiler Mylers., et al. Text Book for Maternal and Child Health Nursing. 1st Edition, W.B.Saunders Company, Philadephia. 2000. 645-655 8. Francine H. Nichols,Elaine swelling., et al. Text Book for Maternal and New Born Nursing Theory and Practice. 1st Edition. W.B.Saunders Company,London.1999. 643-652. 9. M.K.Krishnamenon., B.Palunalappan., (1990) M udaliar and Menosis Clinical Obsteritics. 9th Edition. Madras, Orient Logman Limited Annasalai:133-154 10. Murphy Black Trica. Issues in Midwifery:, Edinburgh Churchil Living Stone. 1995. 220-310

11. Oren D.E. Nursing Concept of Practics,3rd Edition, MC Graw Hill, New York. 1995.12-17. 12. Aelamsm et al, Maternal age & birth in 1980 Jornal of American Medicalcal Association, vol. 247,2002. 483-489. 13. www. Monsterindia.co 14. AIihalh Ali., Sunil J,. et al., Calcitoningene and parathyroid Hormone related peptides in pre-eclampsia effects magnesium Sulfate . Journal obst &Gyae of India, Vol. 97, No.6, June 2005:893-896 15. Bahasibai, m Guss Dekkar., et al., pre eclampsia seminar Journal the lanced, Vol. 365, no. Feb 26,Mar 14-2005: 785-800. 16. Biard D., Epidemic logical aspects of Hypertensive pregnancy. Clinics in Obst and Gyne, Vol.4 no.1, 1998: 531-545. 17. Chira Benedetto., Herbert valensise Chas., A tow stage screening test for Pregnancy induced hypertension and pre-eclampsia. Journal of Obst & Gyne, vol. 92, no.6 Dec.1992. 1005-1011. 18. Davey DB and Macgillivary, The classification and definition of Hypertensive disorders of pregnancy. American Journal of obst & Gyne, Vol. 158, 891-892. 19. Dudley. L., M aternal Mortality associated with hypertension in orders pregnancy in Africa, Asia, Latin America and Canada. 20. Flerd Effectiveness & efficiency in AN. Care Midwifery, 2003: 215-223. 21. Francis, Self care in PIH Nursing Journal of India, Vol. 80, no. 7, 2005. 853. 22. J.Ray K, Visishta., S. Kaur., et al calcium Metabolism in Pre-eclampisa Journal of international Obs & Gyne of India. Vol.3 No.1 2000: 10-15.

23. Keichi Matsubara., Emikoabe, et al., Changes in serum concentration of Tumor necrosis factor & Adhesion molecules in normal pregnant women and those with PIH . Journal of Obst & Gyne of India, VOL. 6, Dec-2003. 169. 24. Kumari . UP Geeta., et al., Self care activities of PIH and marternal outcome, Journal of Nursing India, Mar 2003; 1-4. 25. Leonardo BT., Nursing care of patients with PIH. Phillippine Journal of Nursing, vol.58, 1999; 14-25. 26. Muralidhar Upai., et al,. The effect of placental laterality on uterine artery Duppler velocimetery in normal pregnancy PIH, IUGR. Journal Obst n& Gyne of India, vol.1 2002: 52-55. 27. Vrunakall Joshi., Goullan., et al., Role of Micro Nutrients and Calcuim in pregnancy induced hypertension. Journal Obs & Gyne, Vol.8 No.11. 2000: 15-17. 28. ACOG practice bulletin. Diagnosis and management of pre eclampsia and eclampsia No.33. 2002,159-167.29 29. Paul .F, Hendry .C, Cabrelli.L, Meeting patient and relatives information needs upon transfer from an intensive care unit the development and evaluation of an information booklet, Journal of clinical nursing 2004, march; 13 (13) : 396-405. 30. Joshi HB, News N, Stainthorpe.A. The development and validation of a patient information booklet on ureteric stents; BJU international 2001 Sept ; 88(4) : 32934. 31. Sumati. Effectiveness of planned health education on knowledge and practice of cancer patient regarding management of selected side effects of radiation therapy. Kolar. 32. WHO,UNICEF, UNFPA World bank. Maternal mortality in 2005. Estimates developed by WHO, UNICEF, UNFPA, and the World bank. WHO Geneva 2007.

33. Elizabeth, B.I. An International study to improve the knowledge and practice regarding selected self-care activities of intra partum period among primi mothers admitted in S.A.T. Hospital Trivandrum. University of kerala, India UN PUBLESHED STUDIES: 34.G. Vijaya lakshmi, descriptive study to assess the knowledge of MPHW Regarding antenatal care in selected rural health centers in kolar Dist. 35. A study to assess the effectiveness of structure teaching program among PIH mothers in selected rural health care centers in Rangareddy Dist. 36. S. Mary A study to assess the practices of self care and fetal outcome among PIH mothers attending OPD to GMH, Kurnool, AP. 37. D. Shobarani, Astudy to the effectiveness of information booklet on PIH mothers. Attending OPD to tirupati, AP. Web sites: 38. http:/www.mooreinfo.com 39. http:/www.pubded.coms 40. http;/www.goole.com 41. http;/www.eurpub. oxfordjournals.org 42. http:/biomedicine.org 43. http:/askbaby.com 44. http;/ www.wrogndiagnosis.com 45. http:/www.biomedcentral.com 46. http:/www.birthingnaturally.com 47. http:/www.update.com

SIGNATURE OF 9. THECANDIDATE REMARKRS OF THE 10. GUIDE NAME AND DESIGNATION 11. OF MRS. P. PANDIAMMAL, 11.1 GUIDE Associate Professor, ETCM College of Nursing, Kolar-563101. 11.2 SIGNATURE feasible for the study. The research topic selected is relevant and

11.3 CO-GUIDE

11.4 SIGNATURE 11.5 HEAD OF THE MRS. P. PANDIAMMAL, DEPARTMENT 11.6 SIGNATURE The topic was discussed with the members REMARKS OF THE 12. PRINCIPAL She is permitted to conduct the study. 12.1 SIGNATURE OF THE PRINCIPAL of research committee and was finalized.

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