CHAPTER – I

INTRODUCTION
Background of the study
The delivery of care in nursing is a combination of science and art, driven by a passion for
patient care and respect for the dignity of every client. It is founded on a corpus of knowledge
that is always evolving due to new discoveries and innovations. When providing nursing care,
we should be aware of what we're doing, follow consistent procedures, and use the
fundamentals of good nursing practice.
Respiration is the physiological process by which gases are exchanged between the atmosphere
and the blood, and subsequently between the blood and the cells of the body. As air is inhaled,
it passes through the air passages and is either warmed or chilled to match the body's
temperature. It also becomes wet and saturated with water vapour. Additionally, the air is
cleaned as dust particles adhere to the mucus that covers the lining membrane. According to
Waugh and Grant (2017), blood serves as the means of transportation for oxygen and carbon
dioxide between the lungs and the cells of the body. External respiration refers to the exchange
of gases between the blood and the lungs, whereas internal respiration refers to the exchange
of gases between the blood and the cells of the body.
Asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD),
pneumonia, and tuberculosis (TB) are examples of respiratory disorders that are becoming
increasingly prevalent as serious health issues around the world. As a result of the interaction
between genes and the environment, respiratory disorders are considered to be polygenic. As
is the case with all other chronic diseases, COPD and asthma both include risk factors that can
be modified and those that cannot be modified, and both can be prevented. The most prevalent
risk factor that has been observed on a global scale is smoking cigarettes; nevertheless,
numerous epidemiological studies have gathered sufficient information to suggest that non-
smokers may also be susceptible to developing respiratory disorders of this nature. This
indicates the presence of other factors like environmental tobacco smoke exposure, dust
exposure at work place, outdoor air pollution and indoor air pollution, exposure to biomass
smoke produced during heating and cooking biomass in poorly ventilated houses has become
a important risk factor among women especially in developing countries.
In addition, a low socioeconomic status was discovered to be a significant risk factor in a
number of epidemiological investigations. In the case that the risk factors are successfully
managed, these diseases can be avoided to a significant degree. According to the World Health
Organisation (WHO), non-communicable diseases are defined as "diseases that are chronic,
lifestyle-related, and typically progressive when appropriate intervention is not provided." This
is especially true for respiratory disorders because they are chronic, progressive, and the
majority of the risk factors are tied to lifestyle choices (such as smoking, exposure to biomass
fuel, and so on). Currently, it is the top cause of chronic morbidity and mortality throughout
the globe, and it is anticipated that by the year 2020, it will become the third biggest cause of
death across the globe, and by the year 2030, it will be increasing its prevalence in middle
income nations. According to the global burden of illness study, respiratory disorders are
anticipated to grow to the fifth biggest cause of loss of Disability Adjusted Life Year (DALY)
by the year 2020. This is an increase from their current position. In addition to this, it constitutes
a significant financial and social hardship for sufferers. The conclusion that they reach is that
respiratory disorders are the most significant public health burden, and their incidence is
growing, particularly in emerging nations. It was said by Anand. L. (2017) that asthma is one
of the chronic diseases that is most prevalent all over the world. It has only been in the last
thirty years that it has become a major concern in terms of public health. At the present time,
it is believed that over 300 million individuals all over the world suffer from asthma.
As a result of populations adopting western lifestyles and becoming more urbanised, the
prevalence of asthma symptoms is increasing. When the year 2025 arrives, it is anticipated that
there will be an additional one hundred million people who suffer from asthma. India is home
to roughly 15–20 million people who suffer from asthma. In a study that was conducted in
India and sponsored by the Indian Council of Medical Research (2016), it was found that the
prevalence rate of asthma was 5.0% for males and 3.2% for females who were over the age of
35.
It was reported by the Global Burden of Disease Study (2016) that there were 251 million
instances of respiratory disorders all over the world in the year 2016.During the year 2015, it
is projected that the disease was responsible for 3.17 million fatalities all over the world. This
represents 5% of the total number of deaths that occurred worldwide during that particular
year.Worldwide, countries with low and intermediate incomes account for more than 90
percent of all deaths that are caused by respiratory disorders. According to Guyatt et al. (2015),
asthma is responsible for around one mortality out of every 250 occurring all over the world.
When taking into consideration the effects of chronic lung illness, mortality is not the only
problem that arises; morbidity is an even more significant problem.
Patients who have chronic lung illness experience a decrease in their functional capacity,
primarily as a result of exertional dyspnea, which ultimately results in a decline in their quality
of life.
In 2014, Jindal et al., from the department of Pulmonary Medicine in Chandigarh, conducted a
comprehensive evaluation of all Indian papers pertaining to respiratory illnesses. In the
majority of the 14 studies that were reviewed, the prevalence percentages ranged from
anywhere between 4 and 6 percent for males and between 2 and 4 percent for females.
In the present day, there are 235 million people who are afflicted with asthma. Countries with
low and lower-middle incomes are the ones that experience the highest number of deaths
caused by asthma. There were 3,83,000 deaths that were attributed to asthma in 2015,
according to the most recent statistics that were provided by the World Health Organisation in
December of 2016.
Significance of the Study
According to the World Health Organisation (WHO), asthma is a major non-communicable
disease that is characterised by recurrent attacks of wheezing and shortness of breath. The
severity and frequency of these attacks varies from person to person according to the severity
of the asthma attack. It is possible for affected persons to experience symptoms multiple times
in a single day or week, and for some individuals, the severity of their symptoms increases
when they are engaged in physical activity or when they are sleeping.

Asthma attacks are characterised by swelling of the lining of the bronchial tubes, which results
in the narrowing of the airways and a reduction in the amount of air that is able to enter and
exit the lungs. Symptoms of recurrent asthma commonly result in inability to sleep, weariness
during the day, decreased activity levels, and absenteeism from both school and work. The
mortality rate associated with asthma is quite modest in comparison to those of other chronic
diseases.

On the occasion of World Asthma Day in 2017, the World Health Organisation revealed that
the number of deaths in India that were caused by lung disorders was increasing, accounting
for 11 percent of the overall number of deaths. 142.09 people per one lakh passed away as a
result of a lung disease, with India being the country that ranks top in the world in terms of
deaths caused by lung disorders.An investigation into the prevalence of chronic obstructive
pulmonary disease and asthma among adults in Madurai, Tamil Nadu, was carried out by
Mohamed
Saleem et al., (2017). This investigation was a community-based cross-sectional study that was
carried out in the Kallendiri block of Madurai district. The study population consisted of adults
who were over the age of 30 and were of both sexes. It was a sample size of 480. A semi-
structured questionnaire was used to conduct interviews with study participants, and a peak
flow metre was used to quantify the peak expiratory flow rate. The cluster sampling approach
was used to conduct the interviews. According to the findings of the research study, the
prevalence of chronic obstructive pulmonary disease and asthma was found to be exactly
22.1% among the group that was under investigation. A higher percentage of males (39.2%)
than females (12.2%) were affected by this condition.

The prevalence of chronic obstructive lung disease and asthma was significantly greater among
individuals who were becoming older, were male, were illiterate, had a low body mass index,
smoked, had poor ventilation, and were utilising biomass fuels for cooking. In conclusion, it
was determined that taking into account the fact that chronic obstructive pulmonary disease
and asthma were extremely prevalent among adults living in rural areas, it is necessary to have
a high index of suspicion for chronic obstructive pulmonary disease and asthma among
individuals who are over the age of 30 and have substantial exposure to risk factors.

A quasi-experimental investigation on the impact of the Respiratory Care Bundle on dyspnea

in patients with respiratory issues who were hospitalised to MMIMS & R Hospital was carried
out by J Bindu et al. in 2015. By employing the purposive sample strategy, sixty patients were
chosen. The Modified Borg Dyspnea Scale was utilised to gather data. Patients with respiratory
issues provided the data that was collected. The patients were instructed to perform two hours
of oral hygiene per day: brushing and tooth paste in the morning, washing their mouths twice
a day, at 10 a.m. and 4 p.m., rinsing their mouths with plain water every other hour, and
participating in incentive spirometry every two hours for seven times a day. The Modified Borg
Dyspnea Scale was used to measure dyspnea both before and after the respiratory care bundle
was administered. Following the delivery of the respiratory care bundle, there was a statistically
significant difference (p<0.01) in the dyspnea scores between the two groups, suggesting that
the respiratory care bundle was an effective therapy to reduce dyspnoea.

Therefore, the researcher thought that it was necessary to assess the impact of respiratory
bundle care—which consists of deep breathing exercises, oral care, and incentive therapy—on
dyspnoea in patients with bronchial asthma.
Statement of the Problem

A Quasi-Experimental Study to Evaluate The Effectiveness of Respiratory Care Bundle on

Dyspnoea Among Patients With Bronchial Asthma at Selected Hospitals, Panipat

Objectives

1. To evaluate the dyspnea levels in the experimental group and control group of bronchial
asthmatic patients before and after the test.
2. To assess the impact of the respiratory care bundle on patients in the experimental group
who have bronchial asthma in terms of dyspnea.
3. To determine the relationship between the experimental group's chosen demographic
factors and the post-test level of dyspnea among bronchial asthma patients

Hypotheses:

H1 - The mean post test level of dyspnea will be significantly lower than the pre test
level of dyspnea in the experimental group.
H2 - The mean post test level of dyspnea in experimental group will be significantly lower than
the post test level of dyspnea in control group.
H3 -There will be a significant effectiveness of respiratory care bundle on dyspnea among
patients with bronchial asthma in experimental group
H4 - There will be a significant association between the level of dyspnea and the specified
demographic characteristics among patients with bronchial asthma.

Operational Definition:

EVALUATE: In this study, refers to finding out the efficacy of respiratory care bundle on
dyspnea among patients with bronchial asthma.
EFFECTIVENESS: In this study, it refers to evaluating the extent to which respiratory care
bundle will reduce the level of dyspnoea among patients with bronchial asthma and is measured
with a modified Borg’s dyspnoea scale.
RESPIRATORY CARE BUNDLE: This study, refers to respiratory care which includes the
combination of oral care, deep breathing exercises, and incentive spirometry, which has to be
performed for 30 minutes,3 times per day for 3 consecutive days.
DYSPNEA: In this study, it refers to the level of breathing difficulty among patients with
bronchial asthma assessed with the Modified Borg dyspnoea scale and categorized as No
evidence of dyspnoea, Mild dyspnoea, Moderate dyspnoea, and Severe dyspnoea.

PATIENTS WITH BRONCHIAL ASTHMA: In this study, it refers to the patients who were
diagnosed with Bronchial Asthma, and seeking medical treatment in selected hospitals, Panipat

Assumption:

1. A respiratory care bundle will be an effective intervention in reducing the level of

dyspnea of patients with bronchial asthma.
2. Respiratory care bundle can be easily practiced by patients with bronchial asthma
without having any physical distress.
3. Nursing intervention for patients with bronchial asthma can be promoted by non –non-
pharmacological interventions like respiratory care bundles.
4. Patients with bronchial asthma will accept to perform the respiratory care bundles
an alternative modality to improve the level of dyspnoea

Delimitation:

1. The study only includes people with bronchial asthma who do not have any co-
morbid diseases.
2. The sample size is limited to 60. For patients aged between 31 and 50 yearsThe
data gathering period was limited to six weeks.

Projected outcome:

1. The study will determine the impact of the Respiratory Care Bundle on dyspnea in
patients with bronchial asthma.
2. The respiratory care bundle can be used as a non-pharmacological intervention to
alleviate dyspnea in people with bronchial asthma.

Ethical Considerations

The dissertation committee prior to the pilot study approved the research study. Prior
permission will be obtained from the Principal, Chairman of respective hospitals. The oral
consent will be obtained from each participant of study before starting data collection.
Assurance was given to the subjects that confidentiality will be maintained

Conceptual Framework
This study is grounded on the "J.M. Kenny's Open System Model-1999". All living systems
are open, meaning that there is a continuous interchange of matter, energy, and information.
An open system exhibits varying levels of contact with its surroundings, through which it
accepts input and outputs matter, energy, and information.
The primary components of the open system model include input, throughput, output, and
feedback.
 Chapter – II

Review of literature

Review is a critical summary of research on a topic of interest, often prepared

to put the research problem in the correct perspective or as a basic for an
implementation of project.

- Polit and Beck

Review of literature is an essential component of the research process. It is a critical

examination of publications related to topic of interest. Review should be
comprehensive and elaborate. It helps to plan and conduct the study in a
systematic and scientific manner.For the present study, the related literature was
reviewed and organized as following:

I. Literature related to Bronchial asthma.

II. Literature related to Respiratory Care Bundle.
III. Literature related to effectiveness of Respiratory Care Bundle on dyspnea
among patients with Bronchial Asthma.

Literature related to Bronchial asthma

Merhej T, Zein JG. (2023) Patients and society around the world bear a heavy burden due to
asthma, a prevalent airway illness. However, there has been insufficient success in reducing
the burden of asthma, despite worldwide political commitment sponsored by the United
Nations. In nations with low per capita income, this is especially the case. Many factors have
slowed down the advancement of asthma research and treatment. These include inconsistent
data collection, flawed surveillance methods, a lack of funding, poor access to effective
therapies, poor asthma education, ineffective government policies, fast urbanisation, rising
asthma prevalence, longer life expectancy and obesity rates globally, disease complexity and
heterogeneity, smoking, and environmental allergens and pollution. Developing future plans to
lessen the impact of asthma requires an in-depth familiarity with the difficulties encountered
by the global population.
Shamshad T, Khalique N, Shameem M, Shah MS, Nawab T. (2022) Asthma is a persistent
inflammatory condition characterised by obstructions in the respiratory tract and airways,
leading to recurring episodes of wheezing, shortness of breath, constriction in the chest, and
coughing. Asthma is acknowledged by the World Health Organisation as a primary public
health concern. Although asthma can manifest at any stage of life, the age groups most
frequently afflicted are children and young adults. This study aims to determine the prevalence
of bronchial asthma and its associated factors among school-aged adolescents (6–16 years). A
one-year cross-sectional study was conducted in the field practice areas of the urban health and
training centre and the rural health and training centre of the Department of Community
Medicine, JNMCH, A. M. U., Aligarh, U.P., with school-aged children ranging in age from six
to sixteen years. Utilised was the validated questionnaire from the International Study on
Childhood Allergy and Asthma. A sample size of 902 was determined. The data were entered
and analysed using version 20.0 of the SPSS statistical software with the chi-square function.
It was discovered that 26.9% of the study population was affected by asthma. An individual's
personal history of allergy and familial smoking have been identified as significant risk factors
for asthma. A notable correlation can also be observed between an individual's diet and asthma.

Kumar GS, Roy G, Subitha L, Sahu SK. (2021) People all over the world who have
bronchial asthma have a big public health problem. Not many studies have been done on
bronchial asthma in school children in urban India. To find out how common bronchial asthma
is in school-aged kids and what factors are linked to it. A cross-sectional study was done in
Urban Puducherry with 263 kids in the 8th, 9th, and 10th grades using a modified version of
the International Study on Allergy and Asthma in Childhood questionnaire. A family history
of asthma, the type of fuel used for cooking, where the kitchen is located in the house, the
number of windows in the bedroom, having pets, smoking in the family, birth order, and smoke
outlets were some of the factors that were looked at. The data were looked at using binary
analysis and were shown as percentages or proportions. 5.3% of people had bronchial asthma
at some point in their lives, and 4.2% had a case of asthma in the past year. About 72.7% of
people who currently have asthma had a cold or rhinitis, and 54.5% had itching or bumps and
a dry cough at night. More people in the 12–13 age group (6.5%) have it than people in the 14–
16 age group (3.6%). The numbers for boys (5.4%) and girls (5.2%) were about the same.
There was a significantly higher rate of occurrence in people who had a family history of
asthma, smoked, or didn't have a smoke outlet in their home (P < 0.05). Children in
Puducherry's cities have a big health problem with bronchial asthma. Taking steps to stop
people from being exposed to casual smoking and giving them places to smoke could help
lower the disease burden in the community.

Literature related to Respiratory Care Bundle.

Chen CM, Cheng AC, Chou W, Selvam P, Cheng CM. (2020) Patients using mechanical
ventilation (MV) suffer adverse effects from prolonged physical immobilisation. to implement
an early mobilisation quality improvement project aimed at improving the outcomes of MV
patients in the intensive care unit (ICU). In specifically, we looked at how the ABCDE
bundle—daily awakening, breathing trial, medication coordination, delirium survey and
treatment, and early mobilization—affected the outcomes of motor vehicle patients in the
intensive care unit who were experiencing acute respiratory failure. This is a before-and-after
outcome study that is retrospective and observational. Enrolled were adult patients on MV (N
= 173) admitted to a southern Taiwan medical center's intensive care unit (ICU) with 19 beds.
When patients became hemodynamically stable, a multidisciplinary team comprising a critical
care nurse, nursing assistant, respiratory therapist, physical therapist, and patient's family
performed ABCDE with early mobilisation within 72 hours of MV (twice daily [30 minutes
each time], 5 days/week during family visits and in cooperation with family members).
Differences in MV duration, length of stay in the ICU and hospital, medical expenses, and
intra-hospital mortality before (phase 1) and after (phase 2) bundle care were the primary
outcome variables. Acute Physiology and Chronic Health Evaluation (APACHE) II, blood urea
nitrogen, and creatinine levels were among the significant disparities that Phases 1 and 2
disclosed. Phase 2 patients exhibited a markedly shorter average length of stay in the intensive
care unit (8.0 against 12.0 days); nevertheless, their mean mechanical ventilation (MV)
duration (170.2 versus 188.1 hours) was comparable, and their hospital stays (21.1 versus 23.3
days) and intra-hospital mortality (8.3 versus 36.6%) were lower. The ABCDE care bundle
helped patients with MV who were experiencing acute renal failure; in particular, it reduced
hospital mortality and ICU stays while also saving money.

Mart MF, Brummel NE, Ely EW. (2019) From heavily sedated patients to those that are
mobilised on mechanical breathing with minimal sedation, the clinical approach to critically ill
patients has seen a remarkable transformation during the past few decades. With the goals of
maximising patient recovery, minimising iatrogenesis, and engaging and empowering the
patient and family during their hospitalisation, the ABCDEF bundle is an evidence-based,
multidisciplinary approach to critical illness holistic treatment. The discomfort, delirium, and
readiness to quit sedation and start spontaneous breathing trials are all part of the package that
aims to attain this goal. Patients are encouraged to be mobilised early, restrictions are
discouraged, and family members are encouraged to participate in bedside rounds in order to
enhance communication. This bundle's efficacy decreases, dose-dependently, mortality,
ventilator days, delirium, coma, reliance on restraints, and readmission to intensive care units.
The ABCDEF bundle relies heavily on the respiratory therapist, who is an integral part of the
critical care team. The purpose of this review is to outline the ABCDEF bundle, explain its
components, and give evidence for the impact of the bundle as a whole and of its individual
treatments in the treatment of critically sick patients.

Zafar MA, Loftus TM, Palmer JP, Phillips M, Ko J, Ward SR, Foertsch M, Dalhover A,
Doers ME, Mueller EW, Alessandrini EA, Panos RJ. (2020) A worsening of COPD results
in a faster decline in lung function, a worse quality of life, an increased death toll, and increased
expenses. In order to reduce hospital stays and expenses, the emergency department (ED)
provides short-term care through observation rooms. An approach to enhance outcomes in ED
observation units following COPD flare-ups must be found. We aimed to reduce the number
of 30-day ED visits for COPD flare-ups being treated in observation rooms by using a COPD
care bundle. The research was conducted in an 800-bed academic safety-net hospital that treats
700 patients annually for COPD flare-ups. For patients who were discharged from the ED
observation unit, the all-cause ED return rate (i.e., the outcome measure) was 49% (30 days,
August 2014–September 2016). Included were all patients who were admitted to the ED
observation room due to COPD flare-ups. A multidisciplinary team used iterative plan-do-
study-act processes to implement the COPD bundle. 90% of the time, the objective was
achieved (process measure). The bundle was developed by taking a close look at our inpatient
program's unmet subject needs and failing care delivery. It consisted of five components: a 15-
day appointment, a 30-day supply of inhalers, information on equipment that can be utilised
after discharge, and the appropriate inhaler schedule. We employed statistical process-control
maps to measure both the procedure and the outcome. Subject characteristics and process
attributes were compared using samples of consecutive patients from the baseline (n = 50) and
postbundle (n = 83) periods, which were 5 and 7 months apart. Chi-square tests and t tests with
P <.05 were employed for comparisons. During the baseline period, 410 individuals were
admitted to the ED observation unit, and 165 individuals were admitted during the postbundle
period. 90% of those in the bundle adhered to it after 6 months, and statistical process-control
charts demonstrated a shift in the system as the 30-day ED revisit rate decreased from 49% to
30% (P =.003). Hospitalisation rates from the ED observation unit and general hospital were
same (45% vs. 51%, P =.16). The individuals displayed comparable characteristics at the
baseline and post-bundle periods. If patients rigorously adhered to a COPD care plan, they had
a lower chance of returning within 30 days after receiving treatment in the ED observation unit.

Literature related to effectiveness of Respiratory Care Bundle on dyspnea among patients

with Bronchial Asthma.

Chalder, M.J.E., Wright, C.L., Morton, K.J.P. et al. (2022) Chronic Obstructive Pulmonary
Disease is one of the most common lung diseases in the UK. It's the reason why 10% of
unplanned hospital stays happen every year. A lot of these people are readmitted to the hospital
within 28 days of being sent home. The NHS is trying to make sure that people with long-term
conditions get better coordinated care, but there isn't a lot of studies to show what the best way
is to do this for people with COPD. The point of this study is to find out if standardising care
packages, or "care bundles," for COPD patients who are having severe flare-ups is a useful way
to improve hospital care and lower the number of times they have to go back. This mixed-
methods study will use a controlled before-and-after design to look at the effects and costs of
adopting care bundles for COPD patients who are admitted to the hospital with an acute
exacerbation compared to their usual care. It will use numbers to compare a number of patient
and organisational results between two groups of hospitals: those that use COPD care bundles
to provide care and those that do not. These care packages can be given to COPD patients after
they are admitted, before they are sent home, or at both points in the care pathway. Re-
admission to the hospital within 28 days of discharge will be the main result. The study will
also look into a number of secondary outcomes, such as length of stay, total bed days, in-
hospital mortality, costs of care, and patient and carer experience. A group of nested qualitative
case studies will look into the background and process of care, as well as how COPD bundles
affect staff, patients, and carers in great depth. When the study is over, the data will show how
well care bundles work as a way to manage in-hospital care for people whose COPD is getting
worse quickly. Due to the high number of unplanned hospital admissions for this patient group
and their high rate of re-admission, this evaluation is meant to add to the body of data on care,
which will help patients, clinicians, managers, and policymakers.
Rehab Abd El Aziz (2018) Asthma is a persistent medical condition that predominantly
impacts children and adolescents. The objective of asthma management is to reduce hospital
admissions by controlling the symptoms and ensuring adequate asthma treatment. Therefore,
healthcare professionals should increase their efforts to educate adolescents with asthma
regarding treatment plans. Objective: The purpose of this research was to assess the impact of
bronchial asthma care bundle implementation on adherence, asthma control, and hospital
readmission among adolescents. Research design: A quasi-experimental design employing a
control group in addition to the study group. Context: The present investigation was conducted
within the inpatient division of the Mansoura Government Hospital for Chest Diseases in
Egypt. The sample consisted of 126 asthmatic adolescents who were admitted to the previous
setting after meeting the inclusion criteria. They were randomly allocated into two identical
groups, the control and the study. Four instruments were utilised. One sheet of the structured
interview questionnaire. Performance observation protocols (version 2). 3, Asthma Morisky
Scale of Medication Adherence. 4, Test for Asthma Control. Results: After the intervention,
there were substantial statistically significant differences (p 0.001) in the knowledge and
practice of the adolescents under study compared to the control group (p 0.001). Moreover,
after 30 and 60 days of intervention, nearly half of the adolescents in the study group (49.2%
& 58.7%) had high adherence, whereas less than a quarter (20.6% & 17.5%) of the adolescents
in the control group did. Furthermore, after 30 and 60 days, less than two-thirds of adolescents
in the study group (52.4% & 63.5%) had well-controlled asthma, whereas more than a quarter
of adolescents in the control group (27% & 30.2%) did. Furthermore, after 30 and 60 days
following the intervention, over two-thirds (69.8% & 65.1%) of the adolescents in the study
group did not require hospital readmission, in contrast to approximately one-fourth (22.2% &
28.6%) of the adolescents in the control group. Significant statistical differences were observed
between the two groups following the intervention. Findings: The research concluded that the
implementation of the bronchial asthma care bundle had a positive impact on the knowledge,
practice, adherence, asthma control, and hospital readmission of adolescents. Further
implementation of the bronchial asthma care bundle intervention in additional emergency
departments and hospitals was suggested as a recommendation.
Monira S and Ibrahim M M (2022) In patients diagnosed with chronic obstructive pulmonary
disease (COPD), fatigue, and dyspnea are the prevailing symptoms. Objective: To evaluate the
efficacy of pulmonary rehabilitation, which is included in a practice-based care bundle, in
addressing chronic obstructive pulmonary disease patients' fatigue, dyspnea, functional status,
quality of life, and knowledge. Quasi-experimental design (pre-posttest control trial). The
Department of Cardiology at Aswan University Hospital. A cohort of 100 patients with COPD
was intentionally selected and divided into two groups: the study group and the control group.
The tools are: Seven instruments were utilised in this study: (I) socio-demographic and medical
clinical baseline data; (II) St. George's Respiratory Questionnaire (SGRQ); (III) the Shortness
of Breath Questionnaire from The University of California, San Diego (UCSD); (IV) the
Breathlessness Scale from The Medical Research Council (MRC); (V) the Dyspnea-12
Questionnaire; (VI) the Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF);
and (VII) the Bristol COPD knowledge questionnaire (BCKQ). Before the pulmonary
rehabilitation programme, all of the patients under study possessed inadequate knowledge and
a minority of them engaged in inadequate practices concerning the management of fatigue and
dyspnea. These deficiencies and knowledge significantly diminished following the programme
intervention. The programme improved symptoms of fatigue, shortness of breath, and shortness
of breath in patients with COPD. As a result of pulmonary rehabilitation programme
implementation, the levels of knowledge, dyspnea, fatigue, shortness of breath, and
breathlessness of COPD patients were all enhanced. Key Suggestions: Implementing
comprehensive rehabilitation programmes in outpatient clinics for patients diagnosed with
COPD, accompanied by simplified printed guidelines in the form of brochures or pamphlets,
that comprehensively address the prevention and management of breathlessness and fatigue.
 CHAPTER – III
METHODOLOGY

Research methodologies describe the overall way that things are put together and how accurate

and trustworthy data for the problem being studied is gathered (Polit and Beck).This part talks

about the steps that were taken to see how well the Respiratory care bundle helped people with

bronchial asthma who were having trouble breathing.

During this part of the study, the research method, design, setting population, sample size,

sampling technique, inclusive and exclusive criteria for selection variable, description of tools,

validity and reliability of tools, data collection, and plan for data analysis were all talked about.

RESEARCH APPROACH:

A research method is a planned, organised, empirical, and critical study of natural phenomena
that is guided by theory and hypothesis about how these phenomena are thought to be related.
The researcher will use a quantitative method to check how well the Respiratory care bundle
helps people with bronchial asthma who are having trouble breathing.
RESEARCH DESIGN

A research design serves as a comprehensive plan for carrying out a study. It encompasses

various elements, including the description of the research approach, study setting, sampling

size, sampling technique, tools, and methods of data collection and analysis. Its purpose is to

provide answers to specific research questions or to assess research hypotheses.

For this investigation, a quasi-experimental, pretest-post-test control group design will utilised.

E O1 X O2

C 01 O2

Key

O1 – Pre-test
X – Respiratory Care Bundle

O2 – Post-Test

E – Experimental group

C – Control group

Variables:
Independent variable: Respiratory care bundle
Dependent variable: Level of dyspnea among patients with bronchial asthma.
Settings: The study will be conducted in Dr. Prem Multispecialty Hospital and Team Specialty
Hospital, Panipat.
POPULATION: The population forthe study was the patients with bronchial asthma.
TARGET POPULATION: The target population of the study will be patients with bronchial
asthma.
ACCESSIBLE POPULATION: The accessible population of the study will be the patients
with bronchial asthmawho are all admitted in selected hospitals, Pudukkottai.
SAMPLE SIZE: 60 samples, (30 samples in Experimental group and 30 samples in Control
group).
SAMPLING TECHNIQUES: Non-Probability Purposive sampling technique will be
adopted.
CRITERIA FOR SAMPLE SELECTION:
INCLUSION CRITERIA:
- Patients who were in patient diagnosed with Bronchial Asthma. on regular
treatment.
- Between the age of 31 –50 years.
- available at the time of data collection.
- Willing to participate in the study.
EXCLUSION CRITERIA:
- Patients who were with cardiac,
- renal diseases,
- recent surgeries or any co-morbid illness.
- performing regular breathing exercise or yoga.
- Participated in the pulmonary rehabilitation program within 6 months.
- taking alternative medicines like Siddha, Unani, Ayurveda etc.
DESCRIPTION OF TOOL:
Before the development of the research instrument can commence, an exhaustive literature
review will be performed.
A thorough examination of primary and secondary literature sources will be undertaken to
develop an appropriate instrument. Experts from various fields, including five nursing
specialists, one pulmonology expert, one physiotherapy expert, one biostatistics expert, and
one language expert, contributed their insights and recommendations to the development of the
research instrument.
The instrument for collecting data will comprise two distinct sections. The instrument of
investigation comprised both subjective and objective metrics.
SECTION A - DEMOGRAPHIC VARIABLES:
It consists of demographic data like age, sex, marital status, religion, educational status,
occupation, monthly income, duration of illness, family history of respiratory diseases,
type of treatment taken for respiratory diseases, smoking habits, history of doing physical
exercises, and previous exposure to the incidental education regarding breathing exercises.
SECTION B – ASSESSMENT OF LEVEL OF DYSPNEA:
Modified Borg‟s Dyspnoea scale was used to assess the level of dyspnoea among patients
with Bronchial asthma. Modified Borg‟s Dyspnoea Scale is a 10 point scale which was
categorized under four grading such as No evidence of dyspnea, Mild dyspnea, Moderate
dyspnea and severe dyspnoea based up on the subjective description of level of dyspnea
described by patient.
Score Key
Score Grading
1 Severe Dyspnoea
2 Moderate Dyspnoea
3 Mild Dyspnoea
4 No Dyspnoea
Validity And Reliability Of The Tool:
Validity:
The validity of the tool will be established by consultation with the guide and five experts
in the field of Medical Surgical Nursing, one pulmonologist, one in the field of Physiotherapy,
one in the field of Statistics and one language expert
Reliability:
Reliability of an instrument is the degree of consistency measures that attribute it is
supposed to be measured. Reliability of the tool will be estimated in the study subjects by
using test –retest method.
Pilot study:
Pilot study will be conducted at a private Hospital in Panipatfor a period of one week. A total
6 sample of patients with bronchial asthma were selected (3 samples in experimental group and
3 samples in control group). The sample will be selected by purposive sampling technique.
Informed Oral consent will be obtained and demographic variables will be collected from
the patients with bronchial asthma aged between 31-50 yrs., the level of dyspnea will be
assessed with modified borg‟s dyspnea scale and respiratory care bundle will begiven 3
times a day for about 3 days then post-test will be done, the feasibility and practicability of
the tool was assessed. The data collection will be amenable to statistical analysis and thus
the study was found to be feasible.
Procedure For Data collection:
The period of data collection was about6 weeks. A formal written permission will
be obtained from the chairman of Dr Prem Hospital, Panipat, to carry out the main study.
Samples will be selected with Non-Probability purposive sampling technique. On selection
of the samples, self-introduction will be given.
Informed oral consent will be obtained from the samples. During the data collection procedure,
the subject was asked to sit in the relaxed manner. In pretest, the level of dyspnea was assessed
with Modified Borg‟s Dyspnea Scale. After the completion of pretest, patients will be
instructed to brush with tooth paste in the morning and evening, rinse the mouth with salt
water and followed by plain water before doing deep breathing exercises and incentive
spirometry for 3 times per day, Morning, Afternoon, Evening for 3 consecutive days . Deep
breathing exercises followed by Incentive spirometry will be given for 10 minutes each. The
post test will be conducted on the third day with the Modified Borg‟s dyspnea scale. The
control group will receive the routine medical and nursing care. The participants of the
control group will be informed that their respiratory status will be assessed to determine the
severity of illness.
PLAN FOR DATA ANALYSIS:
The collected data will be arranged and tabulated to represent the finding of the study. Both
descriptive and inferential statistical methods will be used for analyzing the data, planned
to describe the data as percentage, mean and standard deviation and those were used to
analyze the demographic variables. For the distribution of demographic data,simple
percentage will be used. Unpaired„t‟test will be used to compare the effectiveness of the
interventions among experimental and control group. Chi-Square test will be used to find out
the association between demographic variables and level of dyspnoea after the
administration of Respiratory care bundle.
 Research Approach
Quantitative Research Approach

Research Design
Quasi – Experimental Design

Settings
Dr. Prem Hospital - Panipat

Variables
Independent Variables – Respiratory Care Bundle
Dependent Variable - Dyspnoea

Tool
Modified Borg’s Dyspnoea Scale

Data Collection Process

Experimental Group Control Group

Pre-Test Assessment on Level of

Dyspnoea

Respiratory Care Bundle Routine Care

Post-Test Assessment on Level of

Dyspnoea

Data Analysis
Descriptive & Inferential Statistics

Figure – I: Schematic Presentation of Research Methodology

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