الفهرس 
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Abstract
Summary
Bleeding esophageal varices is a life-threatening medical condition that often arises as a complication of advanced liver disease, most commonly due to cirrhosis. These dilated blood vessels in the esophagus can rupture, leading to severe and potentially fatal bleeding. Managing patients with bleeding esophageal varices is a complex clinical challenge, and a multitude of factors can significantly influence clinical outcomes in this critical scenario (Meseeha & Attia, 2023).
The factors affecting clinical outcomes among patients with bleeding esophageal varices are diverse and encompass a wide range of variables, including the underlying cause of liver disease, the severity of cirrhosis, the promptness of medical intervention, the choice of treatment modalities, and the presence of comorbidities. This multifaceted interplay of factors necessitates a comprehensive approach to patient care, with a focus on early detection, effective management of bleeding episodes, and strategies for preventing variceal rebleeding (Baye et al., 2023).
Aim of the study
The study aims to assess factors affecting clinical outcomes among patients with bleeding Esophageal varices through:
1. Assess factors affecting clinical outcomes human– non human(patients, nurses and environmental related factors)among patients with Bleeding esophageal varices.
2. Assess clinical outcomes among patients with bleeding esophageal varices.
Research Question
This study will be conducted for answering the following questions:
1. What are factors affecting clinical outcomes human – non human( patients, nurses and environmental related factors) among patients with bleeding esophageal variceal?
2. What are clinical outcomes among patients with bleeding esophageal variceal?
Subject and Methods:
Research Design
A descriptive exploratory research design was conducted to achieve the aim of this study.
(A)- Setting
This study was conducted in the critical care units at Mahalla hepatology teaching hospital.
(B)- Subject
Group(A): A purposive sample of (98) patients with bleeding esophageal varices based on power analysis calculated by (G Power analysis) (multivariate, two tail, Effect size = 0.25, α = 0.05, Power (1-β) = 0.95) with numerical predictors.
Eligible criteria:
• Adult conscious patients from both genders with bleeding esophageal varices.
• Patients free from malignancy.
Group(B): A convenient sample of all available nurses (38 nurses) in the previously mentioned setting.
Tools of Data Collection
Data was collected using the following tools:
Tool I: Patient interview questionnaire: It included the following:
Part (1): Demographic characteristics of patient’s
it was used to collect patient’s personal data such as: age, sex, academic qualification, marital status, occupation, and residence.
Part (2): Patient’s medical data record
It was utilized to obtain data about medical history of patients including comorbid diseases, prescribed and over the counter medications.
Part (3): patients’ knowledge assessment sheet
It was developed by the investigator assess patients’ knowledge regarding bleeding esophageal varices such as definition, causes, signs and symptoms, complications, diagnosis, prevention and medical management after reviewing recent related literature (Tandon et al., 2018; Sharma et al., 2019).
Tool II: Nurses’ assessment tool: It included the following:
Part (1): Nurses’ Demographic data
it was concerned with demographic characteristics of nurses under study such as age, gender, educational level, years of experience, previous attendance of training courses regarding care of patients with bleeding esophageal varices.
Part (2): Nurses’ knowledge assessment questionnaire
It was developed by the investigator in simple Arabic language to assess nurses’ level of knowledge after reviewing the related and recent literatures (Ahrens et al., 2010; Hussien et al., 2020; Rossian & Crusher, 2017; Mohamed et al., 2021) including; definition, etiology, risk factors, signs and symptoms, diagnostic studies, complications, medical, surgical and nursing management of EVB.
Part (3): Nurses’ practice observational checklist
It was developed by the investigator to assess nurses’ level of practice regarding care of patients with bleeding esophageal varices, based on review of recent related literature (Lynn et al., 2013; Hussien et al., 2020; Shaban et al., 2019). It was comprised 5 parts covering the following procedures (Cannula insertion, blood sampling, nasogastric tube insertion and lavage, blood and plasma transfusion).
Tool III: Factors assessment tool
It was developed by the researcher to assess factors affecting clinical outcomes among patients with bleeding esophageal varices such as patient related factors, which included age, presence of other medical conditions comorbidities, degree of variceal bleeding, Eating High risk food , High risk drinks , Had six small meals , No Exercise , Cough and sneezing , Lifting heavy objects , Constipation and Lifestyle Factors as: Behaviors such as alcohol consumption and smoking. and staff nurses’ factors, which included Knowledge and Expertise, effective communication with the healthcare team and Medication Administration The score was ranging from 0 “Not available” to 1 “Available”.
Tool IV: Clinical outcomes assessment tool:
It was developed by researcher to assess clinical outcomes of patients with bleeding esophageal varices. It included hemodynamic stability, length of stay, persistent or recurrent bleeding and mortality rate.
Results
The findings of the current study can be summarized as:
• The mean age of the studied patients was (64.03±7.68) years, the percentage distribution of age reveals a diverse range, with (46.9%) falling between 50-70 years and (41.8%) above 70 years. As for gender, (58.2%) of them were male. (53.1%) of the studied patient, were uneducated. In addition to (64.3%) of them were un employed and (78.6%) from rural area. While marital status predominantly comprises married individuals (79.6%).
• According to patient’s medical data (57.1%) of the studied patient admitted with melena. (31%) of them had 750-1500ml blood loss. A history of bleeding esophageal varices affected (29.6%), and (55.2%) admitted once. In addition to (37.9%) of them had previous bleeding ranged from 1500-2000 ml.
• According to patient’s medical data (73.5%) of the studied patient had past medical history with (26.4%) had diabetes mellitus and (36.1%) had hypertension. Surgical history is present in (15.3%), with cholecystectomy (46.7%) and appendectomy (26.7%) being notable. In addition to (88.8%) of the studied patients had history takes over-the-counter medications and Usual activities that elevate risk for bleeding esophageal varices include constipation (62.3%) and carrying heavy items (30.6%).
• According to total level of knowledge of patients with bleeding esophageal varices (73.5%) of the patients had an unsatisfactory knowledge regarding bleeding esophageal varices.
• The mean age of the studied nurses 30.68±3.60 years, the age distribution shows a significant portion (60.5%) under 30 years, the majority of them are male (55.3%). Married nurses make up the majority of the nursing workforce (76.3%). Regarding education, (55.3%) of them held nursing bachelor’s degrees. In addition, only (13.2%) of people had training on bleeding esophageal varices, and (60%) of those who had training had it more than five years ago. Roughly (86.8%) of the population also lacked these skills. One-to-five-year and over-10-year experience was held by (28.9%) of them.
• According to total level of knowledge of studied nurses a substantial majority, specifically (76.3%) of them, possessed a satisfactory level of total knowledge.
• Regarding level of total practice of the studied nurses as regard care of patients with bleeding esophageal varices, (78.9%) of them had satisfactory level.
• According to environmental factors regarding care of patients with bleeding esophageal varices, availability of expertise in managing esophageal varices affected (83.7%). Access to advanced diagnostic and therapeutic interventions had an impact on (92.9%). Socioeconomic factors affected (76.5%). Adequate income level had an impact on (91.8%). Education was noted to impact (100%). Social support had an impact on (90.8%). Availability of blood products affected (95.9%). Availability of endoscopic equipment had an impact on (86.6%). Availability of intensive care facilities affected (83.7%). The coordination of care between different healthcare providers impacted (98%).
• According to patient-related factors that have an effect on care of patients with bleeding esophageal varices, Age as a risk factor for esophageal varices affects (96.9%). The presence of other medical conditions or comorbidities, such as liver disease, cirrhosis, hepatitis, hypertension, impacts (86.6%). The degree of variceal bleeding affects (89.8%), the presence of complications affects (83.7%), and the overall severity of the condition affects (81.6%). High-risk eating habits have an effect on (78.6%), high-risk drink consumption on (76.5%), and having six small meals on (80.6%). No exercise impacts (66.3%), while cough and sneezing affect (93.9%). Lifting heavy objects and constipation each have an impact on (100%) of patients. Lifestyle factors like alcohol consumption and smoking that can contribute to the development of esophageal varices affect (98%) of patients. Patient adherence to medications impacts (91.8%), while lifestyle modifications like alcohol cessation, dietary restrictions, and regular follow-up visits affect (89.8%). Patient education and self-management have an effect on (78.6%), and awareness of signs of bleeding impacts (92.9%).
• Regarding clinical outcomes of the studied patients with bleeding esophageal varices, there was hemodynamic stability was observed in (82.7%) of cases. Regarding the length of the current hospital stay, (86.7%) were admitted for 1-2 days. Among the current admissions, (42.9%) experienced persistent or recurrent bleeding. For those experiencing bleeding, (31.0%) of them had 750-1500ml blood loss. Mental status revealed that (87.8%) were aware, and (12.2%) were unaware. Laboratory investigations showed (86.7%) had normal results. (88.8%) discharged from the hospital, while only (11.2%) died.
• Regarding the Relation between level of studied patient’s knowledge regarding bleeding esophageal varices and their socio-demographic data, there was found that factors such as age, gender, marital status, and occupation do not demonstrate substantial connections with knowledge. However, a notable and statistically significant association was identified between academic qualifications and knowledge (p < 0.001). Notably, individuals with higher education levels tend to possess greater knowledge. Furthermore, the place of residence significantly impacts knowledge (p < 0.001). Urban dwellers exhibit higher levels of knowledge, with 61.5% of them having good knowledge, in contrast to rural residents, where only 6.9% display a similar level of knowledge.
• Regarding the Relation between the studied nurses level of total knowledge regarding care of patients with bleeding esophageal varices and their demographic data, there was a statistically significant distinction between nurses’ knowledge and their academic qualifications, years of experience, and previous training courses (0.042, 0.007, 0.021) respectively.
• Regarding the Relation between studied nurses level of total practice regarding care of patient with esophageal varices bleeding and their socio-demographic data, there was statistically significant difference between nurse’s practice and their academic qualification, years of experience and previous training courses.
• According the Correlation between total score of nurse’s knowledge and practice regarding care of patients with bleeding esophageal varices, there was Pearson correlation coefficient (r) between the two scores is 0.319, indicating a significant positive correlation (p=0.037*).
• According multivariate logistic regression analysis for independent predictors of outcome, there was statistically significant predictors of outcomes were academic qualification, Patients knowledge, nurse’s knowledge, nurses practice, environmental factors and patient related factors, with p= (0.012; 0.020, <0.001, 0.040, 0.013, 0.020) respectively.
Conclusion
Based on findings of the current study it can be concluded that, The care and outcomes for patients with bleeding esophageal varices are influenced by several key factors. Effective management is linked to the level of nursing knowledge and practice, as well as environmental factors like resource availability, socioeconomic status, education, and coordinated care. Patient-related factors indicate high adherence to medications, showing a significant commitment to following medical recommendations. This highlights the effectiveness of patient education and self-management practices. Clinical outcomes suggest that most patients experience stable conditions and shorter hospital stays, with only a small proportion facing significant complications like excessive bleeding or death.There was a positive correlation between the total scores of nurses’ knowledge and practice related to the care of patients with bleeding esophageal varices, with a statistically significant.
Recommendations
In the light of the current study findings, the following recommendations are suggested:
• Regular follow-ups for all the studied patients to evaluate their health conditions and detect complications early: This ensures continuous patient care and early detection of issues, which is critical for patient outcomes.
• Continuous evaluation of nurses’ knowledge and practice is essential to identify their needs in ICU regarding assessment and prevention of EVB: Ongoing education and evaluation can directly improve patient care and outcomes.
• Future research should be conducted to examine ICU nurses’ knowledge and practices before and after the implementation of an educational program regarding care of EVB patients: This would assess the effectiveness of educational programs and could lead to improved care.
• Further studies have to be carried out to assess nurses’ knowledge and practices regarding the care of patients with bleeding esophageal varices: This complements the continuous evaluation and focuses on expanding knowledge and improving care.
• Develop a simplified and comprehensive booklet including basic information about esophageal varies bleeding as definition, causes, risk factors, complications, and prevention: This educational tool can support both patients and healthcare providers.
• On-going regular educational and training programs to study patients to improve their knowledge about bleeding esophageal varices: Education is critical, but it is a longer-term strategy compared to direct patient care.
• The study should be replicated on a large sample and in different hospital settings to generalize the results: While important for broader application, it is a more long-term and expansive effort compared to the other recommendations.