http://doi.org/10.33698/NRF0123 -Yogita ,Baljit Kaur ,Meenakshi R.Thami
Abstract : Nursing assessment sheet for the administration of magnesium sulphate is a structured sheet for observing and documenting the condition of the mothers for whom magnesium sulphate is prescribed. Its components include several signs and symptoms which reflects the health status of the mothers. Magnesium sulphate is administered in case of pre-eclampsia and eclampsia and it require continuous observation as higher dose may cause toxicity. For observing the mothers, providing appropriate nursing care and preventing complications, there is a need to have a tool. Hence the need was felt and methodological study was undertaken to develop nursing assessment sheet for the administration of magnesium sulphate. The study was divided into five phases i.e. preliminary preparation, content and construct validity and modification phase, tool feasibility, try out phase and reliability phase. The original tool consisted of 15 items. The content and construct validity was ensured by one to one meeting with the panellist and the reliability of the tool was ensured by internal consistency i.e. Cronbach’s alpha. The value of Cronbach’s alpha (unstandardized), after deleting 4 items was found to be 0.747 and the developed tool was found reliable. So, the final tool was prepared consisting of 11 items. The developed tool would help the nurses to provide better care and thereby preventing complications to the mother and fetus. It is recommended that the developed tool can be applied on larger sample and then screened for reliability so as to generalize the tool.
Key words :
Nursing Assessment Sheet, Administration of Magnesium Sulphate.
Correspondence at :
Yogita
Lecturer,
Amar Professional College of Nursing, Zirakpur
Introduction
Magnesium is a naturally occurring mineral 1. It has been used for many years in obstetrical practice for prophylaxis against seizures in women with pre-eclampsia in addition to its use as a tocolytic drug 2. In severe pre-eclampsia or eclampsia, the total initial dose is 10 to 14 gm of Magnesium Sulphate. Intravenously, a dose of 4 to 5 gm in 250 mL of 5% Dextrose injection, or 0.9% Sodium chloride injection may be infused.
Simultaneously, intramuscular doses of up to 10 gm (5 gm or 10 mL of the undiluted 50% solution in each buttock) are given. 3 The normal plasma level of magnesium is 0.8-1.0 mmol/L and the therapeutic range of magnesium is 1.7- 3.5 mmol/L. There is feeling of warmth, flushing, double vision, slurred speech along with ECG changes when the range of magnesium is 2.5-5.0 mmol/L in the blood. Within the range of 4.0- 5.0 mmol/L, there is reduction in the deep tendon reflexes and above 5.0 mmol/L, there is complete loss of deep tendon reflexes. There is sinoar terial and atrioventricular blockade, respiratory paralysis and Central Nervous System depression if the magnesium concentration rises above 7.5 mmol/L. Serum magnesium concentration in excess of 12 mmol/L may be fatal and results in cardiac failure4,5. Magnesium sulphate leaves the mother’s body through the kidneys6. As magnesium is removed from the body solely by the kidneys, the drug should be used with caution in patients with renal impairment. Urine output should be maintained at a level of 100 ml or more during the four hours preceding each dose. Monitoring serum magnesium levels and the patient’s clinical status is essential to avoid the consequences of over dosage in toxemia.3
The nursing management is mainly focused on the accurate assessment of the patient prior to and during the administration of magnesium sulphate. The assessment par t includes blood pressure, pulse, respiration, intake and output, deep tendon reflexes, level of consciousness, presence of headache/ visual disturbances, lung sounds, presence of epigastric pain, temperature, amount and extent of edema, oozing from injection sites, bleeding gums. Assessment of fetal heart rate and uterine contractions, as per the hospital policy, should be done 7.
Nurses who work in obstetrical units may feel comfortable administering intrav- enous magnesium sulphate. Yet many errors have been reported with this medication8. Nursing management is a critical variable in promoting a positive outcome for both the mother and fetus. The purpose of nursing is for a nurse to assess a patient’s physical problems, make nursing plans, care for the patient and in that process, try to improve the patient’s health condition 9. The peri-natal nurse, in collaboration with the physicians, can use the assessment data as a powerful tool in determining the need to start, adjust or stop magnesium infusion10. Toxicity can be detected using physical manifestations as guide. Clinical signs may be a better indicator than serum level of magnesium. This begins with a review of prenatal records and an interview with the patient to clarify history and take note of any severe headaches, visual disturbances or severe epigastric pain. The physical examination includes baseline vital signs and nurses must be consistent when taking and recording blood pressure. Assessing edema, deep tendon reflexes, breath sounds for crackles, level of consciousness, and intake and output is essential when caring for a pre eclamptic patient (Wong, Perry, Hockenberry, Lowdermilk and Wilson, 2006)11.
It is found that despite of many advantages of magnesium sulphate, there are many instances where if a nurse is not assessing the condition of the patient accurately or in time or due to poor documentation, 12 the health of the mother and the baby may be at risk which may lead to fatality. This study has been planned in an attempt to prevent nurse negligence in administering magnesium sulphate by documenting the condition of critically ill mothers and the fetus and decreases the likelihood of an accidental overdose of drug by communicating through proper documentation by developing a Nursing assessment sheet for the administration of magnesium sulphate. This also increases the chances of identifying an error by assessing the mother timely while administering magnesium sulphate before a significant adverse outcomes occurs and results in providing quality patient care.
Objective
To develop ‘Nursing Assessment Sheet for the administration of Magnesium Sulphate’ to the mothers in Labour Room.
Material and Methods
The study was conducted in the Labour Room of the Nehru Hospital, PGIMER, Chandigarh in the month of August- September 2009, which is one of the premier institute of medical education and research in Nor th India. The PGIMER owns its inception to the vision of Late Sardar Partap Singh Kairon, the then Chief Minister of Punjab and the distinguished Medical educationists of the then combined state of Punjab, supported by the first Prime Minister of India Pt. Jawahar Lal Nehru. It is a tertiary care hospital in North India with a total bed strength of 1359. The Labour Room is on the third level in the Nehru Hospital. It is further divided into different units i.e. OB-II, Delivery room, Nursery, Postnatal room, and Eclampsia room. The total bed strength for the mother is 15. The present study was conducted in natural setting under the uncontrolled conditions. The study consisted of five phases:
PHASE 1: PRELIMINARY PREPARATION
This phase is completed in three steps.
- Review of literature
Review of literature is an impor tant component in development of tool in the research process. The review of literature for the present study was done for nursing assessment, documentation, record maintenance, tool development and nursing process. Books, journals, periodicals have been reviewed for the current topic
- Generation of item pool
An exhaustive list of domains constituting the Nursing Assessment for the administration of Magnesium Sulphate was prepared from literature review, discussion with obstetric and gynaecology and nursing faculty, exper t guidance as well as from the investigator’s personal experience of assessing the patients. .
- Preparation of preliminary draft with guidelines
The blueprint of the Nursing Assessment Sheet for the administration of Magnesium Sulphate has been prepared. Suggestions from the guide and co-guide and personal experience of the investigator played an important role in the preparation of tool. Original Draft Of Nursing Assessment Sheet For The Administration Of Magnesium Sulphate was prepared and the domains were categorically written under the headings as Identification data, History i.e. Medical surgical, Family health, Obstetric history, Investigations done, Assessment of patient at the time of admission, Medical intervention, Nursing assessment and intervention, Items for patient assessment during administration of magnesium sulphate like Blood pressure, Pulse, Respiration, Intake, Output, Kneejerk, GCS Score, Headache, Visual disturbance, Lung sound, Epigastric pain, Temperature, Edema, Oozing/ gum bleeding and Labour and delivery notes.
Development of guidelines for the ‘Nursing Assessment Sheet for the Administration of Magnesium Sulphate’ The investigator developed the guidelines for assessment of patient to whom magnesium sulphate is prescribed. It includes items pertaining to GCS Score, headache, visual disturbance, edema, and signs and symptoms that should be assessed and informed to physician immediately. Experts in the field of nursing and obstetric & gynaecology were consulted to further shape up the guidelines.
PHASE 2. CONTENT VALIDITY AND MODIFICATION.
The Nursing Assessment Sheet was distributed among the panel of 14 experts in the field of obstetrics and gynaecology including Associate Professors, Lecturers, Senior residents and Junior Residents & Faculty members from the National Institute of Nursing Education. They were requested to go through the items and give their suggestions. After discussions and suggestions, the following modifications were done in the Nursing Assessment Sheet and draft was prepared
- Items under obstetric history did not cover any treatment taken outside (in any other health institute). So, it was incorporated in the
- The investigations done did not include platelet count and radio-diagnostic tests So, it was included in the investigations.
- Assessment of patient at the time of admission was well thought-out as per the
- For loading dose of magnesium sulphate, the natal period was
- Labour notes were separated from delivery notes and
No changes were made in the guidelines.
PHASE 3. FEASIBILITY OF THE TOOL
To check the feasibility of the tool, pilot study was conducted from 24th June to 11th July’ 09 in Clean Labour room, Nehru hospital, PGIMER, Chandigarh. A total of 6 mothers were taken for the pilot study. The data was collected by the researcher for each patient. Results of the pilot study shows that the tool was feasible for final data collection, language of the tool was easily understandable & clear, activities to be done at an interval of 1 hr took 5 min, activities to be done at an interval of 2 hr took 5-7 min, activities to be done at an interval of 4 hr took 8-10 min. From the findings of pilot study, the necessary modifications were fur ther done in the tool. The final draft of the tool along with the guidelines was made for implementation on large scale.
PHASE 4. TRY OUT OF MODIFIED TOOL
The modified tool was implemented during the month of August-September 2009 in the Labour Room of the Nehru Hospital, PGIMER, Chandigarh. The staff nurses were taught about usage of the tool along with the guidelines in a group of 3-4 by the researcher. The staff nurse on duty or the investigator assessed and administered the magnesium sulphate to the patient as and when the patient was admitted in the labour room according to developed assessment sheet. The other necessary investigation details were collected and recorded from the patient’s file. The Assessment sheet was tried on 16 mother.
PHASE 5. ANALYSIS & RELIABILITY
The analysis of the data was done by using descriptive and inferential statistics. The patient’s information was summarized by calculating the mean, range, standard deviations and percentages. Sensitivity and Specificity of the items was also calculated. The reliability was calculated by internal consistency i.e. Cronbach’s alpha.
Visual disturbance has the maximum sensitivity i.e. 84.21% while the epigastric pain has the minimum sensitivity i.e. 66.66%. On the other hand, knee jerk has maximum specificity of 20.00% while edema has minimum specificity of 14.28% as shown in table 1.
Table 1 : Comparison of sensitivity and specificity of various items.
| Items | Sensitivity | Specificity |
| 1. Visual disturbance | 84.21% | 18.18% |
| 2. Knee jerk | 82.40% | 20.00% |
| 3. Lung sound | 82.02% | 17.97% |
| 4. Edema | 74.28% | 14.28% |
| 5. Headache | 69.50% | 16.49% |
| 6. Epigastric pain | 66.66% | 17.75% |
RELIABILITY OF THE ‘NURSING ASSESSMENT SHEET FOR THE ADMINISTRATION OF MAGNESIUM SULPHATE’
The reliability of the developed tool was calculated by using Cronbach’s alpha. It is commonly used as a measure of the internal consistency reliability of a psychometric instrument. The Cronbach’s alpha for the developed tool is found to be 0.747 (for the tool to be reliable, the Cronbach’s alpha should be equal to or more than 0.7) and the mean with standard deviation of items is 35.12± 4.20 as depicted in table 2.
TABLE 2 : Value of Cronbach’s alpha, Mean & Standard deviation.
| No. of Items | Mean | Standard deviation | Cronbach’s alpha |
| 15 | 35.12 | 4.20 | 0.747 |
Cronbach’s alpha if item deleted: The Cronbach’s alpha value is more than 0.747 if intake, visual disturbance, lung sound and oozing/gum bleeding deleted which suggests that these items should be deleted from the final tool. The Cronbach’s alpha for the other items is equal or less than 0.747 for the remaining items which indicates that these items should be retained in the developed tool.
TABLE 3 : Value of Scale mean and Cronbach’s alpha if item deleted.
| Items | Scale mean if item deleted | Cronbach’s alpha if item deleted |
| 1. Systolic blood pressure | 31.68 | 0.721 |
| 2. Diastolic blood pressure | 31.00 | 0.704 |
| 3. Pulse | 32.00 | 0.731 |
| 4. Respiration | 32.50 | 0.742 |
| 5. Intake* | 32.12 | 0.750 |
| 6. Output | 32.68 | 0.682 |
| 7. Kneejerk | 33.37 | 0.726 |
| 8. GCS | 33.37 | 0.726 |
| 9. Headache | 33.37 | 0.720 |
| 10. Visual Disturbance* | 33.31 | 0.750 |
| 11. Lung sound* | 33.12 | 0.751 |
| 12. Epigastric pain | 33.25 | 0.736 |
| 13. Temperature | 33.31 | 0.747 |
| 14. Edema | 33.50 | 0.744 |
| 15. Oozing/Gum Bleeding* | 33.12 | 0.751 |
| * Items to be deleted |
After reliability testing, four items are deleted from the developed tool i.e. intake, visual disturbance, lung sound and oozing/ gum bleeding. Hence, the final tool was developed. The items included in the final tool were Systolic blood pressure, Diastolic blood pressure, Pulse, Respiration, Output, Knee jerk, GCS Score, Headache, Epigastric pain, Temperature and Edema.
Results
The developed nursing assessment sheet for the administration of magnesium sulphate was tried on 16 mothers during data collection period. The original tool had 15 items. The internal consistency of the tool was calculated by using Cronbach’s alpha (unstandardized) and mean value found to be 0.747 after deleting four items.
PATIENT ASSESSMENT DURING ADMINISTRATION OF MAGNESIUM SULPHATE MAINTENANCE DOSE: gm.
| DATE | TIME | B.P.
(1 hrly) |
PULSE
(1 hrly) |
RESP
(1 hrly) |
OUT PUT
(1hrly) |
KNEE JERK *
(1 hrly) |
GCS SCORE
(2hrly) |
HEAD ACHE
(2 hrly) |
EPI. PAIN*
(2 hrly) |
TEMP
(4 hrly) |
EDEMA
(4 hrly) |
SITE USED | REMARKS | NAME OF STAFF | |
| 0 hr | |||||||||||||||
| 1 hr | |||||||||||||||
| 2 hr | |||||||||||||||
| 3 hr | |||||||||||||||
| 4 hr | |||||||||||||||
| 5 hr | |||||||||||||||
| 6 hr | |||||||||||||||
| 7 hr | |||||||||||||||
| 8 hr | |||||||||||||||
| 9 hr | |||||||||||||||
| 10 hr | |||||||||||||||
|
11 hr |
|||||||||||||||
|
12 hr |
The deleted items were intake, visual disturbance, lung sound and oozing/ gum bleeding. So, the final tool was developed using 11 items to be observed at different time intervals. The developed tool also screened the over dosage of magnesium sulphate. Overall, out of 16 mothers, the over dosage of magnesium sulphate was been among 2 (12.50% ) mothers due to poor assessment and improper documentation. A sample of 12 hours Assessment sheet Guidelines for patient during the administration of magnesium sulphate shown for the usage of nurses caring for eclampsia patients getting magnesium sulphate.
Guidelines for patient assessment during the administration of magnesium sulphate :
- GCS score
| Eye response | Score | Verbal response | Score | Motor response | score |
| Spontaneously | 4 | Oriented | 5 | Obeys command | 6 |
| To voice | 3 | Confused | 4 | Localizes pain | 5 |
| To pain | 2 | Inappropriate words | 3 | Withdraws | 4 |
| None | 1 | Incomprehensible sound | 2 | Flexion | 3 |
| None | 1 | Extension | 2 | ||
| None | 1 |
- Headache ( dull throbbing headache, migraine like)
present (+) ; absent (-)
- Edema=(a)pitting (b) non pitting
- present on feet (2) present on hands & feets (3) present all over the body
NOTE: Inform physician, if following signs & symptoms appear in patient:
- deterioration in level of consciousness
- absence of kneejerk
- respiration <12 per minute
- urine output < 30ml/hr.
Discussion
Nursing not only include providing care to the patients but also observing and documenting the condition of the patients there by preventing deterioration in the health status of the patients. As magnesium sulphate is one of the most frequently used drugs in case of pre-eclampsia and eclampsia, it requires continuous monitoring of mother’s and fetus condition. The peri-natal nurse, in collaboration with the physicians, can use the assessment sheet as a powerful tool in determining the need to start, adjust or stop magnesium infusion.
The present study was carried to develop A Nursing Assessment Sheet for the Administration of Magnesium Sulphate for the mothers admitted in Clean Labour Room of Nehru Hospital, PGIMER, Chandigarh. Based on the objectives thorough perusal of the literature search and experts opinion the researcher tried to explore the various factors which may be affected if over dosage or inappropriate use of magnesium sulphate which can lead to deterioration in the health status of mother. A 15 items assessment sheet was developed by consulting experts and literature review.
Sunita Lawrence (2002) conducted a similar study on the development of flow sheet for the patients with eclampsia. The quality of the developed sheet was found to be highly sensitive i.e. 87.35% of sensitivity The predictive validity was calculated for each item. Similarly a high sensitivity was reported for the assessment sheet in the present study. The maximum sensitivity was found in visual disturbance i.e. 84.21% while the minimum sensitivity was found in epigastric pain i.e. 66.66%. Whereas the maximum specificity was found in knee jerk i.e. 20% and the minimum specificity was found in edema i.e. 14.28% For the internal consistency, the Cronbach’s alpha value is more than 0.747 if intake, visual disturbance, lung sound and oozing/gum bleeding deleted which suggests that these items should be deleted from the final tool. The Cronbach’s alpha for the other items is equal or less than 0.747 for the remaining items which indicates that these items should be retained in the developed tool. To conclude, the developed nursing assessment sheet for the administration of magnesium sulphate was tried on 16 mothers during try out period. The original tool had 15 items. The reliability (internal consistency) of the tool was calculated by using Cronbach’s alpha (unstandardized) and mean value found to be 0.747 after deleting four items. The deleted items were intake, visual disturbance, lung sound and oozing/ gum bleeding. So, the final tool was developed using 11 items to be observed at different time intervals. The developed tool also screened the over dosage of magnesium sulphate. Further, it is recommended that the developed tool can be applied on larger sample and then screened for reliability so as to generalize the tool.
References
- Magnesium Wolter Kluwer Health, Inc.[cited 2009 Nov 10]. Available from: http:// www.drugs.com/cdi/magnesium-sulfate.html.
- Simpson KR, Knox GE. Obstetrical accidents involving intravenous magnesium sulfate: recommendations to promote patient safety; MCN American Journal of Maternal Child 2004, May- June , 29(3), 161-169.
- Mabie WC, Sabai Hypertensive States in Pregnancy. Current obstetric and gynaecologic diagnosis and treatment; 1994, 388- 390.
- The Women’s: the royal women’s hospital, Magnesium Sulphate Protocol, Clinical Practice Guidelines Revised & updated : 2009 [cited 2009 Dec 02]. Available from: http:// www.thewomens.org.au/MagnesiumSulphate protocolCPG.mht .
- Sidhu Harmini. Management of severe Pre-eclampsia & Eclampsia, Belfast, Clinical Resource Efficiency Support Team (CREST),
- Magnesium sulfate for seizure prevention during Health wise, msn health and fitness. Updated 2008, Nov. 14.[cited 2009 Dec 05]. Available from: http:// health.msn.com/pregnancy/articlepage. aspx? cpdocumentid = 100070791
- Magnesium sulfate: Moderate to severe hypertension in pregnancy. UNC Hospitals, Revised: 12/21/04. [cited 2010 Jan 09]. Available from: http:// nursing.intranet. unchealthcare.org/ servicelines/womens_ services /labourdelivery/most-commonly- used-policies-procedures-and-protocols/ magnesium% 20sulfate,%20moderate %20to%20severe% 20hypertension%20in% 20pregnancy.pdf? searchterm=labourdelivery.
- Preventing magnesium toxicity in The Institute for Safe Medication Practices- medication safety alert![cited 2010 Mar 15]. Available from: http://www.ismp.org/ newsletters/acutecare/articles/20051020.asp
- agano Hiroko, Yasutomi Saori, Development for the nursing process using the Roy Adaptation model: Format Discussion Showing the Thought Annual Report of University of Shizuoka, Hamamatsu College. 2005;18: 83-97.
- Nick JM, Deep tendon reflexes, magnesium, and calcium: assessments and Journal of obstetrics Gynaecology Neonatal Nursing, 2004 Mar-Apr; 33(2): 221-230.
- Nursing 211:Research Final Versions, Fall, 2007;c 2007,Nov.27, Preeclamptic Client:Nursing Strategies & their disadvantages.[cited 2010 Jan 11]. Available f rom: h t t p : / / nur. 211 f 07 r eser achfinal. blogspot.com/2007/11/preeclamptic-client- nursing-strategies & their disadvantages .
- Lawrence Sunita, Development of flowsheet for the patients with Eclampsia, Nursing Journal of India, 2002, July; 93(7),