RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and address Mrs. KRISHNANJANA R.

(in block letters) I YEAR M. Sc. NURSING
DR. M. V. SHETTY COLLEGE OF NURSING
VIDYANAGAR
MANGALORE – 575013.

2. Name of the Institution DR. M. V. SHETTY COLLEGE OF NURSING

VIDYANAGAR
MANGALORE – 575013.

3. Course of Study and Subject M. Sc. NURSING

MEDICAL SURGICAL NURSING

4. Date of Admission to the Course 13.08.2013

5. Title of the study

EFFECTIVENESS OF JACOBSON'S PROGRESSIVE MUSCLE

RELAXATION TECHNIQUE [JPMRT] ON ANXIETY AMONG

HAEMODIALYSIS PATIENTS IN A SELECTED HOSPITAL,

MANGALORE.

6. Brief resume of the intended work

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6.1 Need for the study

Renal failure refers to temporary or permanent damage to the kidneys resulting in the
loss of normal kidney function. There are two different types of renal failure – acute and
chronic. Acute renal failure has an abrupt onset and is potentially reversible. Chronic failure
progresses slowly over at least three months and can lead to permanent renal failure1.

Chronic kidney disease (CKD) is a worldwide public health problem, both for the
number of patients and cost of treatment involved. Chronic Kidney diseases progresses slowly
over at least three months and can lead to permanent renal disease. End-stage renal disease is
when the kidneys permanently fail to work. Chronic kidney disease (CKD) is a condition
characterized by a gradual loss of kidney function over time. Kidney failure may be treated
with haemodialysis, peritoneal dialysis or kidney transplantation. Haemodialysis treatments
are usually performed three times a week2.

According to WHO Global Burden of Disease Project, CKD is the 12th cause of death
and the 17th cause of disability, respectively. Prevalence is estimated to be 8-16% worldwide 3.
In community-based studies, the CKD prevalence has been reported between 0.16% and
0.79%. Approximately 30% of patients with diabetes mellitus (DM) have diabetic nephropathy
and with the growing number of DM patients and aging population there is likely a parallel
increase in CKD incidence2.

In India, according to a survey conducted by the National Kidney Foundation,

approximately 2 lakh people go to kidney failure every year and 1,52,000 new patients require
dialysis every year 4. In US more than 35% of people aged 20 year or older with DM have
CKD and more than 20%of people aged 20 year or older with hypertension (HTN) have CKD.
Complications include increased all-cause and cardiovascular mortality, kidney-disease
progression, acute kidney injury, cognitive decline, anaemia, mineral and bone disorders, and
fracture.

Haemodialysis is the most common method used to treat advanced and permanent
kidney failure. Since the 1960s, haemodialysis became a practical treatment for kidney

failure. Although haemodialysis may be done for acute kidney failure, it is more often
employed for chronic renal disease. It is a major life change that can cause a great deal of
stress and anxiety5. Possible complications of haemodialysis include muscle cramps and

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hypotension (sudden drop in blood pressure). Hypotension may cause you to feel dizzy or
weak, or sick to your stomach. Anxiety as a primary symptom includes all conditions of
indefinite fear and psychic disorders dominated by fear. Anxiety is a normal emotion. All
human beings develop it as a means of protection from danger and threat when we perceive
danger. Human body undergoes a number of autonomic physiological changes such as
perspiration, restlessness, discomfort, palpitation and tightness in the chest5.

All dialysis patients suffer from anxiety as an independent phenomenon, or as a part of

another disease. People with anxiety disorders are also at higher risk of being affected by
depression. So it needs to be addressed before an anxiety disorder can be effectively treated.
Everyone experience anxiety about the future is part of being human and helps us plan ahead
and make better decision.

In a global perspective, the term anxiety has become a part of our every day life. The
concepts of anxiety may differ according to the individual’s state of contexts and
interpretations. It is recognized that certain amount of anxiety is desirable, productive and can
facilitates the individuals to grow but when the anxiety exceeds disturb the normal functions.
Aging is a natural process and an inevitable one.6

It is estimated that about 25% of the world population will experience an anxiety at
some stage of their life. Women are twice more likely to suffer from an anxiety than men.
Unfortunately, only 50% of people receive treatment for their disorder. Anxiety problem often
leads to mental disorders. So it needs to be addressed before an anxiety can be effectively
treated. In India, 51.4% of people have anxiety while doing haemodialysis.7

Anxiety triggers certain physical changes and sensations, including:

 Increased blood flow to the muscles

 Muscle tightening

 Rapid or shallow breathing

 Increased heart rate

 Slowed digestive functioning 8.

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 By using Jacobson’s Progressive Muscle Relaxation Technique (JPMRT), you can
counter these physical changes and sensations to achieve a “relaxation response.” A relaxation
response comes from using relaxation techniques to calm your body. During Jacobson’s
Progressive Muscle Relaxation Technique (JPMR), breathing slows and heart rate and blood
pressure decrease. When muscles are relaxed, they don’t require as much oxygen as when they
are tense. This allows redirection of blood flow from the tense muscles to other areas of the
body, which reduces many of the unpleasant physical effects of anxiety8.

Jacobson’s Progressive Muscle Relaxation (JPMR) is a stress and anxiety management

technique developed by Chicago physician Edmund Jacobson in the 1920s. Jacobson theorized
that anxiety and stress lead to muscle tension, which, in turn, increases feelings of anxiety.
When the body is in a relaxed state, however, there is little muscle tension, leading to
decreased anxious feelings. Jacobson believed that if one’s body is relaxed, one’s mind cannot
be in a state of anxiety8.

Jacobson’s Progressive Muscle Relaxation Technique (JPMRT) has been shown to be

beneficial in easing anxiety, and reducing anxiety has been shown to improve the symptoms of
many psychological and medical conditions. This technique is often recommended for people
with anxiety disorders, insomnia, chronic pain and other disorders. It is technology free, user
friendly and no finance is involved.

From the above studies it is inferred that there has been increasing trend in the
prevalence of anxiety disorders among patients undergoing haemodialysis. So researcher has
found need to relieve the anxiety among haemodialysis patients by using Jacobson’s
Progressive Muscle Relaxation Technique (JPMRT) which is effective in reducing anxiety by
alternately tensing and relaxing the muscles.

6.2 Review of literature

Following are the studies and related researches regarding occurrence of anxiety among
Haemodialysis patients and the importance of Jacobson’s Progressive Muscle Relaxation:

A study was conducted on “Evaluation of depression and anxiety in haemodialysis

patients” in Mashhad University of Medical Sciences, Iran, during the year 2007. A total of
150 patients regularly treated with haemodialysis were chosen through sensor sampling. This
study revealed that 51.4 percent prevalence of State Anxiety and 49.0 percent of Trait Anxiety.

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This study showed that a substantial number of haemodialysis patients experienced depression
and anxiety9.

A cross-sectional study was conducted on “Prevalence of anxiety in Chronic Kidney

Disease Patients on Haemodialysis”. A total of 135 out of 296 patients gave consent for the
study, out of 105 (77.7%) were males and 30 (22.2%) were females. Eighty-nine (65.9%) out
of 135 patients fulfilled the criteria of anxiety and depression. In our study, using the HADS, it
was elicited that 57.30% (51/89) of our ESRD patients had depression out of which 39.2%
(20/51) of our maintenance dialysis patients were having mild depression (HADS 5-9),
24.49% (13/51) had moderate depression (HADS 10-14) and 13.72% (7/51) had severe
depression (HADS >15) and 42.69% (38/89)had anxiety disorder out of which 47.36% (18/38)
had mild anxiety (HADS 5-9), 28.94%(11/38) had moderate anxiety (HADS 9-14) and 23.68%
(9/38) had severe anxiety (HADS >15) 10.

A study on efficacy of progressive muscle relaxation for reducing anxiety in elderly

clients was conducted.15 anxious elderly clients were randomly assigned to experimental
group and control group and measured the anxiety using state-trait anxiety inventory. The
Results show that 60% of elderly people have a significant reduction in anxiety level 11.

A cross-sectional study was conducted from the Department of Psychiatry, University

of Medical Science Tehran, Iran, in 2000 to determine the extent of anxiety-dialysis
relationship from all patients who were at least receiving one year of dialysis treatment. The
anxiety rate was evaluated by a psychiatric assessment, under the supervision of psychiatrist
using Hamilton anxiety test. The study was conducted on 54 controls and 51 case groups. The
anxiety score in control and case groups were 34±2.4 and 24.9±8.2, respectively. The results
were analyzed by Kruskal Wallis statistical method, showing that the rate was significantly
higher in patients. Dialysis could be of important in provoking anxiety 12.

A quasi-experimental study was conducted in Ege University Nursing School, Izmir,

Turkey, on the effect of progressive muscle relaxation training (PMRT)on anxiety levels and

quality of life in dialysis patients. The sample size was 46 dialysis patients. The duration of
PMRT was 6 weeks. State-trait anxiety inventory scale and quality of life rating scale were
used for data collection before and after training. The study revealed that PMRT for dialysis
patients helps to decrease state and trait-anxiety levels and has a positive impact on quality of

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life The mean state-anxiety score before and after PMRT was found as 43.4±4.3 and 28.9±2.8,
respectively (P<0.001). Similarly, the mean trait-anxiety scores before and after PMRT were
found as 43.6±9.5 and 31.1±6.5, respectively (P<0.001). When the QoLI-dialysis score was
examined it was 28.7±3.2 before PMRT and 29.6±2.3 after PMRT (P<0.01). The results of the
study demonstrate that PMRT for dialysis patients helps decrease state- and trait-anxiety levels
and has a positive impact on QoL.13

A study on effects of progressive muscle relaxation training on quality of life in

anxious elderly clients was conducted on a sample of 110. The sample was relaxation therapy
and lifestyle education for 6 weeks. Both groups were followed up one month after completion
of the intervention. The results shows that there is significant reduction in state anxiety
(p<0.01) and trait anxiety (p<0.01).The study concluded that progressive muscle relaxation
therapy is an effective therapy for improving psychological health and quality of life in
anxious elderly clients 14.

An experimental study was conducted in The Department of Psychiatry and Renal

Dialysis Unit and Office of Education Development, University of Alabama School of
Medicine and Hospitals, Birmingham, USA, to investigate the effectiveness of progressive
Relaxation in chronic haemodialysis patients. Experimental group of 38 patients were
presented a 30-minute self-instructional, colour videotape on progressive relaxation (PR)
exercises and a control group of 23 patients viewed a neutral videotape. Both groups were
given the State-Trait Anxiety Inventory while on the dialysis machine, before and after the
actual viewing, the experimental group significantly reduced its state anxiety level while the
control group remained the same. Patients who reported higher levels of state anxiety and
experienced tension more frequently tended to achieve the greater benefit from the
programme. It is postulated that PR can be a useful resource to overcome the severe anxiety
related to the stresses of chronic haemodialysis 12.

A study on relaxation therapy for anxiety was conducted in elderly persons. The study
evaluates the effects of an 8 week progressive muscle relaxation therapy regimen for a sample
of 10 elderly anxious clients using Beck anxiety inventory. The Results shows that the overall
anxiety level (50% or greater) in 7 subjects were significantly reduced 16.

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 An experimental study on “depression, anxiety, body image, sexual functioning, and
dyadic adjustment associated with dialysis type in chronic renal failure” by Qanakkale Onsekiz
Mart University School of Medicine, Turkey. The study shows that depression (20.64±15.20)
and anxiety levels (14.72±12.36) were significantly higher in haemodialysis group compared
to peritoneal dialysis (13.54±12.51; 12.74±11.21) and control groups (7.17±5.58; 9.86±9.19).
In peritoneal dialysis group, as depression and anxiety levels increased, body image was
disturbed and sexual satisfaction decreased. In peritoneal dialysis group, body image
(86.98±23.63) was better than haemodialysis group (101.58±26.51) and was not different from
the control group (83.67±22.11). In haemodialysis group, as depression and anxiety levels
increased, body image was disturbed. In both groups, long-term dialysis disturbed body image
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.

6.3 Statement of the problem

Effectiveness of Jacobson’s Progressive Muscle Relaxation Technique [JPMRT] on

Anxiety among Haemodialysis Patients in Selected Hospital, Mangalore.

6.4 Objectives of the study

The objectives of the study are to:

 determine the existing level of anxiety among haemodialysis patients by using

Hamilton Anxiety Rating Scale.

 evaluate the effectiveness of Jacobson’s progressive muscle relaxation technique on

anxiety among haemodialysis patients using Hamilton Anxiety Rating Scale.

 find the association between pre-level anxiety scores and selected demographic
variables.

6.5 Operational definitions

 Effectiveness: In this study, it refers to the outcome of Jacobson’s progressive muscle

relaxation technique that has been identified in terms of difference in scores of anxiety.

 Jacobson’s Progressive Muscle Relaxation Technique: In this study, Jacobson’s

Progressive Muscle Relaxation Technique (JPMRT) refers to the technique used to

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 reduce the anxiety level of haemodialysis patients. Here the investigator teaches ways
to relax the whole body slowly, by making the person concentrate on each part of the
body from feet to face, until a stage of complete relaxation for 15-20 minutes. It is
administered to the experimental group only.

 Anxiety: It is a state of being troubled and uneasy or feeling of apprehension, worry or

distress of mind of patients who are undergoing haemodialysis. In this study level of
anxiety will be assessed by using Hamilton Anxiety scale.

 Haemodialysis Patients: Haemodialysis patients refers to patients who are clinically

diagnosed to have chronic renal disease and undergoing haemodialysis.

 Hospital: Hospital is the setting where patients with chronic kidney disease are
admitted and undergoing haemodialysis.

 Hamilton Anxiety Rating Scale: In this study, Hamilton anxiety scale refers to a scale,
used to assess the level of anxiety of patients undergoing haemodialysis in a selected
hospital.

6.6 Assumptions

The investigator assumes that:

 Patients undergoing haemodialysis have some kind of anxiety.

 Jacobson’s progressive muscle relaxation technique may help reduce anxiety related to
haemodialysis.

6.7 Hypotheses

The hypothesis will be selected at 0.05 level of significance.

H11: There will be a significant difference between the mean pre-test score and the mean
post test score of anxiety among experimental group and control group.

H12: There will be a significant association between pre-test scores of anxiety and the

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 selected demographic variables.

6.8 Variables

 Independent variable: Jacobson’s Progressive Muscle Relaxation Technique

 Dependent variable: Anxiety

6.9 Delimitations of the study

The study is delimited to:

 Patients who are admitted to the selected hospital only.

 Patients with chronic kidney disease undergoing haemodialysis in a selected hospital,

Mangalore.

 Patients who can understand Kannada or English.

7. Material and methods

7.1 Source of data

The data will be collected from chronic kidney disease patients undergoing
haemodialysis in selected hospital, Mangalore.

7.1.1 Research design

Quasi experimental design.

Phase I Phase II Phase III Phase IV

Sample Pre-test (O1) Treatment (R) Post-test (O2) Effectiveness (E)

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 Experimental Assessment of Administration Assessment of
Group anxiety using of Jacobson’s anxiety using
Hamilton progressive the same
anxiety score muscle Hamilton
relaxation anxiety rating
technique scale.
E= O2-O1
Control Assessment of Assessment of
Group anxiety using anxiety using
Hamilton the same
anxiety rating Hamilton
scale anxiety rating
scale

7.1.2 Setting

The study will be conducted in a selected hospital at Mangalore where chronic kidney
disease patients are undergoing haemodialysis.

7.1.3 Population

Population selected for the study would comprise of chronic kidney disease patients
undergoing haemodialysis in a selected hospital, Mangalore.

7.2 Method of data collection

7.2.1 Sampling procedure

In this study, a type of non-probability sampling, that is, purposive sampling technique
will be used.

7.2.2 Sample size

Forty chronic kidney disease patients undergoing haemodialysis would comprise the
sample. Out of the 40 patients, 20 will be in the experimental group and 20 will be in the
control group.

7.2.3 Inclusion criteria for sampling

Patients:

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 who are available during the period of data collection.

 who are willing to participate in the study.

 who are able to follow the instruction

 whose anxiety score is between 18-30 on the Hamilton Anxiety Rating Scale.

 both gender.

7.2.4 Exclusion criteria for samplings

Patients:

 who are unconscious.

 who are critically ill.

 who have muscular disorder.

 who are unable to hear.

7.2.5 Instruments intended to be used

 Hamilton anxiety rating scale

 Semi structured questionnaire for demographic variables.

7.2.6 Data collection procedure

Step I: Prior to data collection, permission will be obtained from the authority for conducting
the study.

Step II: Assessing the anxiety level using Hamilton anxiety rating scale for both groups.

Step III: Forty patients undergoing haemodialysis with anxiety scores between 18-30 will be
selected based on inclusion criteria and randomly assigned to control group and experimental
group.

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 Step IV: Patients of the experimental group will be taught Jacobson’s progressive muscle
relaxation technique for 15-20 minutes everyday for 2 weeks.

Step V: Reassess the anxiety level by using the same Hamilton Anxiety Rating Scale.

Step VI: Prepare the data for analysis.

7.2.7 Plan for data analysis

The data collected will be analyzed using descriptive and inferential statistics. The
investigator will use descriptive statistical techniques such as mean, median, mode, standard
deviation and percentage and inferential statistical technique like paired ‘t’ test and chi square
test.

7.3 Does the study require any investigations or interventions to be conducted on

patients, or other animals? If so please describe briefly.

Yes.

7.4. Has ethical consideration been obtained from the institution in case of the above?

Yes. Ethical clearance has been obtained from the ethical committee of the college.
Consent from the sample will be taken at the time of data collection.

8. References

1. Alfred D. Overview urogenital disorders.[updated on 2012 May; cited on 2013 Dec 6 ]

Available from: URL:http://medicalcenter.osu.edu/patientcare/healthcare_services/
urinary_bladder_kidney/urogenital_disorders/overview_urogenital_disorders/
end_stage_renal_disease/pages/index.aspx.

2. Ilangovan G, Veerappan I, Abraham G. Chronic kidney disease: current status,

challenges and management in India. Chapter 130. [online][updated on 2013;cited on
2013Nov23].Availablefrom:URL:http://www.apiindia.org/medicine_update_2013/chap
130

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3. Rastogi S R .Global scenario of chronic kidney disease.[updated on 2012;Cited on
2013 Nov 15];Available from: URL:http://renalcareindia.org/statistics.aspx

4. Alladi J. Life after kidney failure. [online][ Updated on 2007 Oct ;Cited on 2013 Dec
20];Availablefrom:URL:http://www.thehindu.com/2007/08/24/stories/20070824531211
00.htm

5. Richard CJ. Self-care management in adults undergoing haemodialysis. Nephrology

Nursing Journal . published on 2006 Jul-Aug, [Cited on 2013 Dec 8] 33(4):385.
Available from:URL:http:// http://www.iosrjournals.org_self-care management in
adults undergoing hemodialysis.

6. Arora K .Introduction of anxiety, medicine net. [online] [updated on 2006 Jul 9; cited
on2013Nov23];Available from:URL:http://www.medicinenet.com/anxiety/article.htm.

7. Boemer RJ. Anxiety in elderly people. Fort Scholar Neurological Psychiatry. Published
on 2004 [cited on 2013 dec12];72(10):564-73.Available from:URL:http://
http://www.docstoc.com/anxiety in elderly people.htm

8. Davis M, Eshelman E, Mckay M. The relaxation and stress reduction workbook, 5 th ed.
Oakland: New Harbinger Publications Inc. published on 2000 Jul 6,[cited on 2013 Nov
18];38(5):234-36.Available from:URL:http://www.pubmed.com/relaxation and stress
reduction workbook/htm.

9. Fatemeh N, Fatemeh G, Pourghazneyn T, evaluation of depression and anxiety in

haemodialysis patients. Medical Journal of Mashhad University of Medical Sciences.
published on 2008, [cited on 2013 Oct 23];51(3):176-1.Available
from:URL:http://www. http://www.info.com/evaluation%20depression and anxiety in
hemodialysis patients.

10. Tanvir S, Butt G, Taj R. Prevalence of depression and anxiety in chronic kidney disease
patients on haemodialysis. Published on 2012,[Cited on 2013 Nov 25]52(5):152-
4.Available from:URL:http://www.medinet/depression and anxiety in CKD patients on
hemodialysis/com

11. Rankin EJ, Gilner FH. Efficacy of progressive muscle relaxation training in reducing
anxiety among elderly. Journal of Aging :Published on 2004 Dec [cited on 2013 Nov

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 18];77(3):1395402.Availablefrom:http://www.ncbi.nlm.nih.gov/pubmed/8170796_Effi
cacy of progressive Muscle relaxation for reducing state anxiety among elderly adults
on memory tasks.

12. Tanvir S, Butt G, Taj R. Prevalence of depression and anxiety in chronic kidney disease
patients on haemodialysis. Published on 2012,[Cited on 2013 Nov 25]52(5):152-
4.Available from:URL:http://www.medinet/depression and anxiety in CKD patients on
hemodialysis/com

13. Yildirim YK, Fadialogla C. Study on effect of PMRT on anxiety levels and quality of
life in dialysis patients. Edtna Ercaj 2006 Apr–Jun[cited on 2013 Nov 25];32(2):86-
8.Available from:URL:http://www.pubmed.com/effect on PMRT on anxiety/htm

14. Dehdari T. Effects of progressive muscle relaxation training on quality of life in

anxious elderly clients. Indian Journal of Research, published on 2009 May; [cited on
2013 Oct 18];129(5):211-6.Available from:URL:http://www.medinet.com_effect of
PMRT on elderly clients.

15. Arena JG. Relaxation therapy for anxiety in elderly. Psychological Aging, published on
1988 Mar,[cited on 2013 Dec 20] ;3(1):121-6. Available from:
URL:http://www.recentmedicalfindings.com/relaxation therapy for anxiety in
elderly.htm.

16. Oyekçin DG, Gülpek D, Sahin EM, Mete L. Depression, anxiety, body image, sexual
functioning, and dyadic adjustment associated with dialysis type in chronic renal
failure. published on 2012,[cited on 2013 Oct 22];43(3):227-41. Available
from:URL:http:// http://recentmedicalfindings.com/depression anxiety body image and
dynamic adjustement in dialysis patients.

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9. Signature of the candidate

10. Remarks of the guide It is very common that the patients who are
undergoing haemodialysis will have anxiety .The
JPMRT, is a cost effective method to reduce
anxiety .Hence it is recommended.

11. Name and designation of (in block letters)

11.2 Guide PROF. (MRS.) B. V. KATHYAYANI

PRINCIPAL AND HOD
MEDICAL SURGICAL NURSING,
DR. M. V. SHETTY COLLEGE OF NURSING,
KAVOOR, VIDYANAGAR
MANGALORE -575 013.

11.2 Signature

11.3 Co-guide (if any)

11.4 Signature

12 12.1 Head of the department PROF. (MRS.) B. V. KATHYAYANI

PRINCIPAL AND HOD
MEDICAL SURGICAL NURSING,
DR. M. V. SHETTY COLLEGE OF NURSING,
KAVOOR, VIDYANAGAR
MANGALORE -575 013.

12.2 Signature

13. 13.1 Remarks of the Chairman and Principal

13.2 Signature

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