RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Ms. MERLIN PACKIA SMITHA1ST YEAR MSC NURSING

MEDICAL SURGICAL NURSINGSUSHRUTHA COLLEGE OF NURSING

BANGALORE.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

MS.MERLIN PACKIA SMITHA1 YEAR MSC NURSINGSUSHRUTHA COLLEGE OF NURSING,#23. PAPAIAH GARDEN, DIAGONAL ROAD,CHENNAMANAKERE, ACHUKATTU,BANASHANKARI III STAGE,BANGALORE – 85.

2 NAME OF THE INSTITUTION

SUSHRUTHA COLLEGE OF NURSING

3 COURSE OF THE STUDYAND SUBJECT

DEGREE OF MASTER SCIENCE IN NURSING, MEDICAL-SURGICAL NURSING.

4 DATE OF ADMISSION TO THE COURSE

07/06/2010

5 TITLE OF THE TOPIC

A QUASI EXPERIMENTAL STUDY TO EVALATE THE EFFECTIVENESS OF CRYOTHERAPY IN REDUCING PAIN AMONG PAPIENTS WITH RHEUMATOID ARTHRITIS IN SELECTED ORTHO HOSPITALS AT BANGALORE.

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Let my care remove the Pain”

Every one has experienced some type of degree of pain, yet the concept of

pain is difficult to communicate. The experience of pain is complex, involving, emotional and

cognitive components. A Person in pain feels distress or suffering and seeks relief. The nurse

uses a variety of intervention to bring relief. The recommended hierarchy of management

should consist of non pharmacological treatment first then drugs and if necessary surgery.

There are various non pharmacological methods that can help to relieve the pain perception

such as distraction, biofeedback, cryotherapy ,hot application, music, laughter, touch therapy

etc.

Cryotherapy is a treatment in which the patients are exposed to extreme cold for short

duration. The term “Cryotherapy” Comes from Greek word Cryo(KPUO) Means cure. The

immediate effect of skin cooling and analgesia last for 5 minutes but the release of

endorphins can have lasting effect, where the pains and signs of inflammation are found

suppressed for weeks.

Cryotherapy induces effects both locally and at the level of the spinal cord via

neurological and vascular mechanisms. Topical cold treatment decreases the temperature of

the skin and underlying tissues to a depth of 2 to 4 cm, decreasing the activation threshold of

tissue nociceptors and the conduction velocity of pain nerve signals this results in a local

anesthetic effect called cold-induced neuropraxia.

According to Shanti,B.,Rangwani(2008) Rheumatoid arthritis is a long term disease

that causes inflammation of joints and surrounding tissue. It affects the joints on both sides of

the body that consists of fingers, knees and feet.. Arthritis exhibits pain, stiffness in

affected joints.1

Rheumatoid Arthritis affects on estimated 10 Million Indian, three forth of them

women. It can strike at any age but usually appears between ages 20-50. The hands are most

commonly affected, but it can affect most joints of the body. Highly variable and difficult to

control, the disease can severely deform joints. Some people become bedridden.

Studies shows that the female hormone estrogen may be partly responsible it is no

coincidence that lupus tends to flare during pregnancy, when a womens estrogen level may

raise to 100 times pre-pregnancy level.

In Rheumatoid Arthritis the auto immune reaction primarily occurs in the synovial

tissue. Phagocytosis produces enzymes with in the joint. The enzymes break down collagen,

causing edema, proliferation of the synovial membrane, and ultimately pannus formation.

Pannus destroys cartilage and erode the bone. The consequence is loss of articular surface

and joint motion.

Clinical manifestations of Rheumatoid arthritis vary, usually reflecting the stage and

severity of the disease. Joint pain, swelling, warmth, erythema and lack of function are classic

symptoms. Palpation of the joints reveals spongy or boggy tissue.

The US Arthritis foundation advices all women to be aware of the warning signs of

arthritis and to seek prompt diagnosis and treatment the warning signs are

o Persistent pain and Stiffness on arising

o Pain or swelling in one or more joints

o Tingling sensation in finger tips, hands or feet.

o Unexplained weight loss,

o Fever

o Anemia

o Fatigue.

6.1 NEED FOR THE STUDY

Each and every individual has experience of pain and know the joy of pain relief and

know the agony and frustration associated with inability to relieve pain. Pain in Rheumatoid

arthritis patients will cause immobility, swelling. Pain is often managed with the help of

various modalities include pharmacological and non pharmacological approaches.

Cryotherapy embraces vast varieties of uses which pain reduction, reducing specially

swelling, promote healing decreasing temperature for locally applied tissues.

The national women’s help center (2007) N7 estimate that about 2.1 million people or

one percent of USA adult population have rheumatoid arthritis. It affects women 3 times

more than man in USA. Mitots Hospital (2006) N7 Prevalence of rheumatoid arthritis in India

about 10 million. Most of them are women. Who are deserted by their husbands.

Ramachandra medical college and research center (2006)N7. Prevalence of rheumatoid

arthritis in Tamilnadu around 103 Lakhs adult population . as given by The Hindu (2007)N7

Prevalence of rheumatoid arthritis in Bangalore is 115000 adult population.

Spotlight research (2007)N3 reveals work place dropout rate in women with

Rheumatoid arthritis remain high.

Hiovonen Kawtiainen (2003)N2 done a study on effectiveness of different

cryotherapies on pain and diseases activity in active rheumatoid arthritis and ministered

whole body cryotherapy for 2 to 3min among 60 patient. 2-3 Cryotherapy sessions daily for

one week, reports revealed pain seemed to decrease more in Cryotherapy treatment.

Saeloy (2002)N4 done a study on effect of local application of cold or heat for relief of

pricking pain. cold by means of ice water pack and hot by means of hot water bottle the

reports reveals hot bag no such effect but the application of cold promote relief pain

sensation.

Vituli.V, Badi (2007)N4 conducted a study on effect of superficial heat and cold used

among Rheumatoid arthritis patients among 30 patients the pain threshold was measured

before and after warm bath and ice massage. The findings reveals that the pain threshold is

raised 10-30 min after cryotherapy but not after warm bath.

Currently there is no curative therapy for Rheumatoid Arthritis therefore more

patients are subjected to various life long treatment modalities so researcher find interest to

do the study on pain relief through Cryotherapy among patients with rheumatoid arthritis .

6.2 REVIEW OF LITERATURE

According to Nancy Burns (2005)B8 a review of Literature in research report is

a summary of current knowledge about a particular practice, problem and includes what is

known and not known about this problem.

The number of studies collected regarding cryotherapy, Rheumatoid Arthritis

and pain have been reviewed systematically as follow:

Studies Related to level of pain among patients with Rheumatoid Arthritis.

Studies Related to Rheumatoid Arthritis.

Studies Related to Cryotheraphy.

Studies Related to effect of Cryotherapy among Rheumatoid Arthritis patients.

.

Studies Related to Level of Pain among Patients with Rheumatoid Arthritis

Connelly M , keefe F.J (2007) N11 conducted a study on effect of day-to-day affect

regulation on pain experience of patients with rheumatoid arthritis . 94 adults were selected

and assessed daily for 30 days. The findings revealed that the day-to-day regulation of

negative and positive effect is a key variable for understanding the pain experience of

individuals with rheumatoid arthritis is a potentially important target for intervention.

Keefe F.J Anderson T (2007) N11 conduct a study on randomized , controlled trial of

emotional disclosure in rheumatoid arthritis 98 client were selected and helped them

emotionally by trained clinician and out come measured through pain level, disability , stress

after 2 months the finding revealed that verbal emotional disclosure about stressful

experience was little benefit for people with RA.

Frantomca ( 2006) N11 conducted a study on relationship of psychiatric history to pain

reports in rheumatoid arthritis patients. 41 RA patient with a current episode of major

depression were divided into two sub groups with previous psychiatric history (n-20) and

with out previous psychiatric history (n-21) the findings revealed that psychiatric history

appears to predispose person with concomitant RA and major depression to report less pain.

pain reduction following anti depressive treatment than those persons without psychiatric

history.

Multon KDC (2001) N11 conducted a study on effects of stress management on pain in

rheumatoid arthritis. The subjects were (n-131) were randomly assigned to 1-3 groups stress

management group, attention group as standard are control group. The finding revealed that

the stress management group had increased pain threshold than other two group.

Megsboals AM (1993) N11 conduct a study on level of pain and fatigue in patients with

rheumatoid arthritis Among (n-50) subject MC gill pain questionnaire and visual analogue

scale was used to measure.the pain level the finding revealed that the pain was continuous

duration in patients with rheumatoid arthritis.

STUDIES RELATED TO RHEUMATOID ARTHRITIS

Leams, Pittler MH (2007)N4 Conducted an experimental study to evaluate the

effectiveness of taichi for treating rheumatoid arthritis. quality was assessed using the jadad

score on disability index, effectiveness on pain reduction compared with education plus

stretching exercise.The finding revealed that the value of Tai Chi is not effective treatment in

rheumatoid arthritis for this indication therefore remains unproven.

Kvien T.K (2004)N7 conducted a study on Epidemiology and burden of illness of

rheumatoid arthritis.The findings reveals that it affect between 0.5% to 1 % of adult

population world wide, prevalence more in women than men, work disability leads to

reduced productivity and early retirement.

Casimiro (2002)N11 conducted the experimental study to evaluate the effect of

acupuncture and electro acupuncture for the treatment of rheumatoid arthritis among 84

clients 42 in each group one group receives acupuncture and another one receives electro

acupuncture the findings revealed that release of endorphine and morphine substance thus

inducing local or generalized analgesic effect.

Robinson, casimiro (2002)N4 conducted a study on thermotherapy for treating

rheumatoid arthritis by randomized controlled trails quality was assessed by using 5 point

scale the finding revealed that superficial moist heat and cryotherapy.can be used as palliative

therapy. Also paraffin wax baths combined with exercise can be recommended for beneficial

short effects for arthritic hands.

Ann Rheum (2001)N11 conducted the randomized clinical trial method to evaluate the

effect of intensive exercise on patients with rheumatoid arthritis among 64 patients. The

intensive exercise programme consisted of knee and shoulder dynamic and romantic muscle

strengthening exercises five times a week.The finding revealed that a short term exercise

programme inactivate rheumatoid arthritis and is more effective in improving muscle

strength.

Sarzi-puttinip(2000)N11 conducted a study to evaluate the effects of diet therapy in

patients with rheumatoid arthritis, 50 RA patient were selected randomly they treated for 24

week by two different dietary regimen.The improvement assess through Rhchies index ,ESR,

tender and swollen joints, weight variations. the findings reveals that dietary modification

either by modifying food supplements or reducing weight may give some clinical benefit

STUDIES RELATED TO CRYOTHERAPY

Greensterina (2007) N4 conducted a study on therapeutic efficiency of cold therapy

after intra oral surgical procedures duration of treatment 10-20 min every 2 hrs for 2 days.

The findings revealed that ice applied after surgical procedure may reduce swelling and

discomfort.

Heriuchi H (2004) N2 conduted a study on continuous local cooling for pain relief

follow total hip arthoplasty among 40 patients, subjects were randomly assigned in to two

group. Cryotherapy was given 1-4 days following surgery the pain score was assessed

through visual analog scale the findings revealed that postoperative analgesic use by

cryotherapy group pain level is significantly lower than control group.

Sand Rheumatod (2000)N4 Conducted a randomized controlled trial study to evaluate

the cryotherapy for acute ankle sprains sample size is sportsmen (44) and general public 45

with acute ankle sprain by randomization they separated in to two groups one group is treated

with standard ice application other one treated with intermittent ice application function, pain

swelling were recorded one, two, three, four and six weeks after injury the study finding

revealed that intermittent application may enhance the therapeutic effect of ice in pain relief.

Kuzhathaivel(2000)N4 conducted an experimental study to evaluate the effectiveness

of cryotherapy on post operative pain reduction among 30 arthroplasty patients.Cryotherapy

was given for the period of 3 times a day for continuous 3days numerical rating scale was

used before and after cryotherapy intervention.. The findings revealed that the pain level was

reduced significantly in experimental group than in control group.

Albrechs (1996)N2 conducted a study on effect of continuous cryotherapy on the

surgically traumatized musculo skeletal system among 24 patients following elective knee or

hip replacement surgery. The findings revealed that the effect of cryotherapy which decreases

50 % of post operative pain as well as increased range of motion level.

Yopokurotol (1992)N2 conducted a study on cryo electro therapy in the treatment of

osteoarthritis patients. 105 client were selected and divided in to three group. group 1

received cryotherapy group II received sinusoidal modulated currents group III received cryo

electrotherapy the finding revealed that effectiveness was highest in cryo electrotherapy than

other methods.

Studies Related to Effect of Cryotherapy among Rheumatoid Arthritis

Metzger D, Protzw (2006)N8 conducted a study on whole-body cryotherapy in

rehabilitation of patient with rheumatoid arthritis. The sample consisted 120 patients (75%

women, age 30-67) pain level were assessed using verbal and numerical rating scales the

patient were treated 2.5 minutes under -105 degree c the finding revealed that the pain

reduction last for 90 minutes and whole body cryotherapy is an essential part in

rehabilitation programme.

Hirvonen (2003)N10 conducted single blinded study to evaluate the effectiveness of

different cryothrapies on pain sixty patients with active seropositive rheumatoid arthritis.

Were treated with whole body cryopthrapy at-110 degree c, -60 degree c and application of

cool air and use of cold pack locally the patients had 2-3 cryotherapy sessions daily for one

week the result reveals that whole body cryotherapy is not superior to local cryotherapy in

RA patients.

Resker J.J (1994)N4 conducted a study to evaluate and compare the effects of locally

applied heat and cold treatment among 39 patient with rheumatoid arthritis. By using simple

random technique, selected patients in to four treatment group (ice chips, nitrogen, lingo-

paraffin and placebo short wave). The result revealed that intrarticular temperature is

decreased by superficial cold and not by hot.

Vitull.v Bablic (1993)N4 conducted a study on influence of heat and cold in

rheumatoid arthritis. Amongst 30 patients pain threshold was measured before and after

warm bath and ice message. The finding revealed that the pain threshold is also raised 10 and

30 min after cryotherpy but not after warm bath.

Halwa B and Negruse (1992)N10 conducted a study to analyzes the hormonal and

homodynamic changes during whole body cryotherapy among 63 patients. They were treated

for 14 days once daily by cooling the body for 2 minutes periods in cryogenic chamber the

findings revealed that the cryogenic chamber treatment does not affect the homodynamic

status such as heart rate, blood pressure and hormonal levels.

Baste K.W, Essiger H, (1984)N8 conducted an experimental study on ultrasound

Doppler analysis of arterial blood flow before and after cryotherapy. Cryogel pack for 15

minutes applied in knee region for 19 patients then dorsalis pedals was analysed with an

ultrasound Doppler apparatus the finding revealed that there was no increase of the flow of

velocity during the test.

Rheumatol J (1983)N8 conducted an experimental study on immunologic dynamic in

cryotherapies for Rheumatoid Arthritis. Five patients with erosive Rheumatoid Arthritis who

had previously experienced a favorable response lymphoplus mapheresis. They were treated

with cryotherapy. It was performed 9 times in weeks using a membrane filtration device. The

findings revealed that cryotherapies might be a safe and effective technology in treating

patients with rheumatoid arthritis.

STATEMENT OF THE PROBLEM

A Study to Evaluate the Effectiveness of Cryotherapy in Reducing Pain among

Patients with Rheumatoid Arthritis in selected Ortho Hospitals at Bangalore.

6.3 OBJECTIVES OF THE STUDY

To Assess the pain level of the patients with Rheumatoid arthritis in experimental

group and control group before Cryotherapy.

To Evaluate the effectiveness of Cryotherapy among patients with Rheumatoid

arthritis.

To Compare the level of pain in patients with Rheumatoid arthritis in

experimental group and control group after Cryotherapy.

To Determine the association between the pain level of patients with Rheumatoid

arthritis with their selected demographic variables.(Age, Sex, duration of illness,

duration of treatment).

6.4 RESEARCH HYPOTHESIS

H1 :The mean post pain score will be significantly lower than the mean pre pain score

of experimental group with Rheumatoid arthritis who had Cryotherapy.

H2 :There will be a significant difference between post test level of pain score on

experimental group and control group.

H3 :There will be significant association between the pain level of Rheumatoid

arthritis patients with their selected demographic variables.(age, sex, duration of

illness, duration of treatment).

6.5 RESEARCH VARIABLES

Selected demographic variables age,sex, duration of illness, duration of treatment.

6.6 OPERATIONAL DEFINITIONS

Evaluate

It refers to making judgment or estimation of the degree of success in meeting goal

and measuring the implementation of cryotherapy for reducing pain.

Effectiveness

Refers to the out come of cryotherapy in terms of pain relief among patients with

rheumatoid arthritis.

Cryotherapy

Therapeutic application of cold pack can help to reduce the pain of arthritis by

numbing the nerves surroundings the affected joints.

Pain

Pain is an un-pleasant subjective sensory and emotional experience associated with

actual or potential tissue damage.

Patients with Rheumatoid Arthritis

It is a chronic systemic progressive inflammatory connective tissue disorder affecting mainly

the peripheral joints

6.7 ASSUMPTIONS

All Rheumatoid arthritis patients will experience varying degree of pain

Cryotherapy will help to reduce pain

Cryotherapy technique will have no adverse effect on the subjects.

6.8 LIMITATIONS

Patients with Rheumatoid arthritis

Patients who are willing to participate in the study

7.0 MATERIAL AND METHODS

Research methodology is one of the vital sections of a research proposal since the

success of any research mostly depends up on the methodological issues that are followed in

the execution of the research work. The roles of methodology consist of procedures and

techniques, for concluding the study.

This chapter deals with the methodological approach adopted for the study. It includes

description of research approach, research design, variables, setting of the study population,

sample, criteria for sample selection, sampling technique, development and description of

tools, data collection procedure and plan for data analysis.

7.1 SOURCES OF DATA

Data will be collected from men and women with rheumatoid arthritis between the

age group of 30 to 65 in selected ortho hospital at Bangalore.

7.2 METHOD OF COLLECTION OF DATA

Data will be collected by structured interview schedule.

7.2.1 RESEARCH DESIGN

Polit and Hungler (1995)B12, stated that the research design incorporated the most

important methodological decisions that a researcher makes in conducting a research study.

A quasi-experimental design was chosen for the study without randomization.

7.2.2 RESEARCH APPROACH

The research Approach used for this study was Quantitative approach to evaluate the

effectiveness of cryotherapy among Rheumatoid Arthritis patients.

7.2.3 RESEARCH SETTING

The study will be conducted in selected ortho hospitals at Bangalore

7.2.4 POPULATION

The population of the present study comprises of men and women with Rheumatoid

Arthritis between the age group of 30 to 65 in selected ortho hospitals at Bangalore

7.2.5 SAMPLE SIZE

The sample size of the present study will be 100 samples.

7.2.6 SAMPLING TECHNIQUE

Non – probability convenience sampling technique will be used to select the sample

for the study.

7.2.7 CRITERIA FOR SAMPLE SELECTION

Inclusion Criteria

Patient who are diagnosed as sero positive Rheumatoid arthritis

Both male and female patients

Patient is on NSAID treatment

Patient who are willing to participate.

Exclusion Criteria

Patient who are diagnosed as sensorial deficit and impaired vascular circulation in

hand and feet.

Patients who had previous exposures with cryotherapy

7.2.8 DESCRIPTION OF TOOL

The instrument consists of 2 parts

Part 1 : Consists of demographic variables of Rheumatoid Arthritis patients

Part II : McCaffery numerical rating scale to asses the levels of pain among patients with

Rheumatoid Arthritis.

7.2.9 DATA ANALYSIS METHOD

Data analysis is through descriptive measures.

7.3 DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE CONDUCTED ON

PATIENTS OR OTHER HUMANS ON ANIMALS?

The study will be conducted on patients with rheumatoid arthritis in selected ortho

hospitals at Bangalore.

7.4 HAS THE ETHICAL CLEARANCE HAS BEEN OBTAINED FROM YOUR

INSTITUTION?

Permission obtained from research committee of Sushrutha College of nursing.

Informed consent will be taken from the hospitals where the data will be collected.

8. LIST OF REFERENCES. BOOKS:

1. Bare Brenda, etal (2008) Brunner and suddarth Text Book of Medical and surgical

nursing (11th ed) London: Saunders company.

2. Black Majorca (2001) Med & Surgical 3rd edition. Harcourt Publications-Missouri

3. Brighton etal(2000) Clinical orthopaedics and related research (1st ed)

London:Lippincott publishes- London

4. Donna. (1999) “Medical and surgical nursing across the health London: sauders

company.

5. John Crawford etal(1996) 12th ed outline of Orthopaedics, Chruchin Livingstone

publications- London

6. Lewis, et al (2004) nied & sur assessment and mgt of clinical problems (6th ed) st

louses most by publications

7. Nicholas et al (2006) 20thed Davidson’s principles and practice of needs Elsevier

publications.

8. TNAI, (2007) Fundamental of nursing Procedure manual, (1st ed) Anupam

Publications-New Delhi.

9. T.Brighton Carl(2000) Clinical orthopaedics and related research Ist ed who hers

company, Slipknot publishes- London.

10. Susen Jacab et al (1997) Nursing Principle and Practice (ist ed) , Omayal Achi college

Publications-India

11. Rick daniels et al, 2007 contemporary medical-surgical nursing (1st ed) haryana

Thomson`s Publications.

12. Patricia etal,(2007), Fundamentals of nursing, (2nd ed) thomos Publication-US

13. Shella, A. Scorentina(2004) Mosby`s Text book for nursing Assistants, (7thed)

Missouri Elsevier publications.

14. Particia A.potter, anne griffin perry (2006) fundamental of dorsing (6th ed)

missoori :mosby publication.

15. vasan.R.S (1998) text book of medicine (1st ed) new delhi : orient Longman

publications

16. Dr.Shanti B,Rangwani (2000) arthritis and joint pain new Delhi: voluntary health

association of India publications

17. kothari,C.r.(2004). Research methodology method and techniques. (2nd ed) New

Delhi: new age international Ltd publications.

18. Nancy bords & Susan. (2005) the practice of dorsing research 5th ed

19. Polit.F Denise, (2004), Nursing Research Principles and method 5thed Philadelphia

Lippincott publications

20. An introduction to Bio statistics a manual for students in health science, (3rd ed) new

Delhi: prentice publications

JOURNALS

1. Bindu shaiju, (2008) psychological problem of pa with RA and guidelines for health

professionals Xciz (9) 202 -204

2. Mrs.Kavitha narang (2007) theory of holistic, NNt, comfort, 3(1) 36 -39)

3. Ms.Vaishali jagtap (2007) a study asset of Planned teaching on nurses abnout pain

NNT, 3(3) 60-63

4. USr. Pushpita Moist Ice pack, NNT 4 (3) 4-8

5. MRs.Anbasurendra Kumar (2008, Rheumatoid arthritis, NNT 4(3) 24-29

6. Vetriselvi (2007) Pacifier and a strakegy in the pain management NNT 3(9)

7. Acharya Anoop (2004) dietherapy for arthritis, MNT 5(1) 52-53.

8. John John Christopher (2001) Arthritis, Herald of health, 92(8) 25.

9. jayalakshmi.S(1998) Lifestyle and arthritis, Herald of health 89(7) 15

10. Himalaya Drug. Co (1999) Role of diet in Rheumatoid arthritis IJCP`s medinews

16(31) 19

11. Drug alert (2005) Drug for rheumatoid arthritis medinews 1(15) 12

12. Lancet (2006) combination therapy for rheun arthritis mednews 1(15) 9

13. Ryan (2003) perception of control in (10)3 36-38 patients with rheumatoid arthritis.

Nursing time.

9. SIGNATURE OF THE STUDENT:

10 REMARKS OF THE GUIDE: The topic which is selected by the Candidate is

relevant and appropriate and it attempts to decrease the pain among patients.

11. NAME AND DESIGNATION PROF. A. NAGARAJAN

OF GUIDE: HOD OF MEDICAL

SURGICAL NURSING

11.1 GUIDE NAME AND ADDRESS: PROF. A. NAGARAJAN

HEAD OF THE DEPARTMENT

MEDICAL SURGICAL NURSING

SUSHRUTHA COLLEGE OF

NURSING

BANGALORE-85

11.2 SIGNATURE OF THE GUIDE:

11.3 HEAD OF THE DEPARTMENT PROF. A. NAGARAJAN

NAME AND ADDRESS: HEAD OF THE DEPARTMENT

MEDICAL SURGICAL NURSING

SUSHRUTHA COLLEGE OF

NURSING

BANGALORE-85

11.4 SIGNATURE OF THE H.O.D:

12. REMARKS OF THE PRICIPAL:

13. SIGNATURE OF THE PRINCIPAL: