RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

NIDHA K JOHN,KANJIRATHINKAL HOUSE,SOUTH VAZHAKULAM P.O,ERNAKULAM DIST,KERALA-683105

2. NAME OF THE INSTITUTION

MANASA COLLEGE OF NURSING, MALUR.

3. COURSE OF STUDY AND SUBJECT

Master Degree In Nursing (Medical Surgical Nursing)

4. DATE OF ADMISSION TO COURSE

JUN-2012

5. TITLE OF THE TOPIC A QUASI EXPERIMENTAL STUDY TO EVALUATE THE EFFECT OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE AND ATTITUDE REGARDING EARLY AMBULATION AMONG CLIENTS UNDERGOING ABDOMINAL SURGERY IN SELECTED HOSPITAL, KOLAR.

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6. BRIEF RESUME OF THE INTENDED WORK.

6.0 INTRODUCTION:-

The longer a person has been immobile the longer it will take to regain

strength, balance and co-ordination.

The word rehabilitation comes from the Latin word “rehabilitare”meaning to

make fit again. It is defined as the process of restoration of skills by a person who has

had an illness or injury so as to regain maximum self – sufficiency and function in a

normal or as near normal manner as possible. The concept of rehabilitation becomes

important when providing exercise and activity for patients. In the past it has usually

referred to the restoration of health or functions to a handicapped person. This is still true,

but the dimension of prevention has been added to the concept. The purpose of

rehabilitation is to prevent the loss of function as well as to restore as many functions as

possible. Both physiological and psychological functions are included. There are

extensive variations in patient’s needs and their potential for rehabilitation. Nurses play

important roles in both prevention and restoration of functional loss in health agencies

and in the homes1.

Early mobilization is a widely practiced and important component of

postoperative care following open upper abdominal surgery. Its benefits were first

reported in the 1940s when early mobilization was observed to hasten recovery and

reduce the incidence of postoperative pulmonary complications. Early mobilization

include: moving in bed, sitting out of bed, and standing, ambulating on the spot, hallway

ambulation, and low intensity exercise2.

Upright mobilization assists in the prevention of functional decline and may have

a positive effect on depression and anxiety. In the past, the measurement of upright

mobilization has presented a challenge to the researcher. Upright mobilization following

upper abdominal surgery has been measured as the time taken to achieve mobility goals

such as sitting out of bed, ambulating with assistance, or ambulating independently2.

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Among the adverse effect of lengthy bed rest that have been noted are : a slowing

down of the basal metabolic rate, a decrease in muscle strength, tone ,and size ,postural

changes ,constipation , increased vulnerability to pulmonary and urinary tract infection ,

circulatory problems such as thrombosis (development of a clot in the blood stream) and

embolism (which occurs when the clot becomes detached and travels through the blood

stream until it comes to a vessel too small for it to pass through , where it lodges).The

degenerative process affects bone and skin tissues as well3.

The main side effect of immobilization are increased pulse rate, as the heart work

harder in an attempt to cope with the extra amount of blood “ dumped” into the general

circulation from the legs when the body is lying down. There is increased excretion and

severe depletion of calcium, nitrogen and phosphorous. The person usually develops

feelings of anxiety and frequently hostility as a result of disturbed functioning of physical

and mental activity, as well as disruption of his sleep3.

The dangers of prolonged bed rest have been well documented in numerous study

reports, books and articles in both the nursing and medical literature over the past 30 or

40 years. The custom of early ambulation of patients following surgery and acute illness

was introduced just after World War II. The results have been phenomenal in preventing

complications and hastening patient’s recovery4.

Early ambulation helps the client to meet outcomes of measurably muscle mass

strength and ability to independently move all joints through complete range of motion.

Other measure important to the client impaired physical mobility requires interventions

that help client become increasingly able to move about in the environment. This

increasing level of movement is termed progressive mobilization and includes such

activities as “dangling” at the side of the bed, transferring from bed to chair or wheel

chair, walking a measurable distance5.

The different types of abdominal surgeries are liver transplantation,

cholecystectomy, spleenectomy, appendicitis, gastrectomy, pyloroplasty, herniorrhaphy,

resection of duodenum and colon, kidney transplantation, nephrectomy, lower segment

caesarean section these post op surgery patients can’t mobilize, so encourage them for

early ambulation.

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Therefore early ambulation plays an important role in the prevention of

postoperative complications after abdominal surgery and improves the self care activities

of the patients. Delivering the appropriate health education paves the way to achieve this

goal.

6.1 NEED FOR THE STUDY:-

The term abdominal surgery broadly covers surgical procedures that involve

opening the abdomen. Surgery of each abdominal organ is dealt with separately in

connection with the description of that organ. Diseases affecting the abdominal cavity are

dealt with generally under their own names (e.g. appendicitis) 6.

Data monitor’s epidemiologists expect to see a small increase in the number of

major abdominal surgeries between 2010 and 2020 in the seven major markets (the US,

Japan, France, Germany, Italy, Spain, and the UK). The number of abdominal surgeries

is expected to increase from around 7,436,000 surgeries in 2010 to 8,109,000 surgeries in

2020. In 2010, Data monitor expects that the number of abdominal surgeries will differ

significantly by age group. In the seven major markets, there will be approximately

166,400 surgeries in those under 15, 5,125,000 in those between 15 and 44, 1,194,000 in

those between 45 and 64, and 950,300 surgeries in those over the age of 657.

The world wide ratio of hernias are over 1 million abdominal wall hernia repairs

are performed each year, with inguinal hernia repairs constituting nearly 770,000 of these

cases. Approximately 25% of males and 2% of females have inguinal hernias in their

lifetimes; this is the most common hernia in males and females . Approximately 75% of

all hernias occur in the groin; two thirds of these hernias are indirect and one third direct

Indirect inguinal hernias are the most common hernias in both men and women; a right-

sided predominance exists. Incisional and ventral hernias account for 10% of all hernia.

Only 3% of hernias are femoral hernias8.

Common general post operative complications include atelectasis and pneumonia,

orthostatic hypertension, decreased cardiac output and stroke volume, urinary retention,

negative nitrogen balance, depression and sensory deprivation, decrease tissue sensitivity

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to insulin, deep vein thrombosis, constipation and fecal impaction, loss of muscle

strength and decubitus ulceration9.

A prospective investigation was conducted among two hundred patients who

underwent abdominal surgery at the US Army Hospital, Okinawa, Japan, between

November1972 and March 1974 to determine the incidence and significance of pleural

effusion after abdominal surgery. After studies they find that pleural effusions occurred

after all types of abdominal surgery but were more common after upper abdominal

surgery10.

Acute atelectasis may occur as a post-operative complication. The incidence of

pneumonia after upper abdominal surgery ranges from 3% to 16% and from 5% to 7%

after lower abdominal surgery. However, lesser complications, such as atelectasis and

pleural effusions, occur more frequently. In a large series, 63% of patients had atelectasis

and/or pleural effusion detected on postoperative chest radiographs10.

Deep vein thrombosis (DVT), usually involving a leg vein and pulmonary

embolism also will occur associated with deep vein thrombosis and can be collectively

referred to as venous thrombo embolism (VTE). Venous thrombo embolism is an

important cause of peri-operative mortality and morbidity. Atleast 30 cases of deep vein

thrombosis identifiable by phlebography can be suspected among 100 patients who have

undergone major abdominal surgery11.

Surgical patients are more susceptible to developing pressure ulcers than general

acute care patients. The incidence rate of occurance of pressure sore who had undergone

abdominal surgery are 56%12.

Paralytic ileus also can occur after abdominal surgery. Postoperative ileus occurs

in approximately 50% of patients who undergo major abdominal surgery in United

States13.

Human need continuous self - care maintenance and regulation and provide this

by caring for self, which enables purposeful action. Self care activities maintain life,

health and well being. Health refers to the state of a person, which is characterized by

soundness or wholeness of developed human structures and bodily and mental

functioning. Well being refers to a person’s perceived condition of contentment, pleasure,

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happiness, movement toward self – ideals, and continuing personalization. By giving this

early ambulation patient can able to achieve his/her daily activities as much as earlier. It

will improve the self confidence of the patient. It will facilitate the faster recovery14.

The investigator from the personal experience has observed that after abdominal

surgery the patient may have more prone to get pleural effusion, paralytic ileus, atlectasis,

and neuromuscular complications due to prolonged bed rest. Education to patient about

early ambulation after the abdominal surgery will help the patient to understand more

about complications of immobility after abdominal surgery. It will encourage the patients

to get out of bed so early .Thereby the patient can reduce the length of stay in hospital

and avoid unnecessary stress due to hospitalization and can able to resume his/her

activities as early as possible. This has motivated the researcher to plan a video assisted

teaching program to educate about early ambulation among the patients undergoing

abdominal surgery.

6.2 REVIEW OF LITERATURE:-

A literature review is summary of previous research on a topic which can be

either a part of a large report of a research project, a thesis or bibliographic essay that is

published separately in scholarly journal. The purpose of literature review is to convey

the reader what knowledge and ideas have been established on topic and what are the

strength and weakness. It allows the reader to bring up to date reading the state of

research in the field and familiarizes the reader with any contrasting perspective and view

point on the topic. There are many reasons for beginning a literature review before

starting a research paper.

A prospective observational study was conducted among 55 patients who had

undergone upper abdominal surgery. The aim of the study was to know about the

effectiveness of early upright mobilization following upper abdominal surgery. The study

concluded that the uptime over the first post operative day predicted the length of hospital

stay15.

A randomized trial was conducted among 66 patients who had undergone

abdominal surgery for cancer. The aim of the study was to know the effective of post

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operative ileus duration in patients with cancer recovering from abdominal surgery. The

study concluded that the rocking – chair motion has positive effect on reducing post

operative ileus after abdominal surgery16.

A retrospective analysis was performed among 138 patients between July 2007 to

December 2009 The aim of the study was to know about the efficacy of early

mobilization with early abdominal rehabilitation .The study revealed that early

mobilization with early abdominal rehabilitation significantly reduces the incidence of

post operative delirium/confusion and decrease the length of hospital stay17.

A retrospective study was performed among 54 patients who had undergone open

segmental colorectal resection without an ostomy. The aim of the study was to assess the

feasibility of mobilization after surgery. This study revealed that strict early mobilization

with decreased intravenous fluid administration was effective in reducing hospital stay

among the patients undergoing colorectal resection without any increase in

complications18.

A study was conducted among 182 patients who had undergone splenectomy

between 2001 and 2008.The aim of the study was to evaluate the efficacy and adverse

effect after post operative early mobilization for elderly patients. This study revealed that

post operative complications, such as pneumonia and urinary tract infections was

observed in 24(26.4%) in delay mobilization group and 11 (12.1%) in early mobilization

group and suggest that early mobilization after spleenectomy prevents post operative

complications19.

A study was carried out to find the effectiveness of early ambulation for the

prevention of post operative ileus after abdominal surgery among 40 patients. The study

concluded that it is mainly occurs due to the delay in gastrointestinal motility. Early

ambulation helps to improve the gastrointestinal motility and can prevent the occurrence

of postoperative ileus20.

A study was carried out to determine the effectiveness of fast track rehabilitation

after aortic iliac vascular procedure among 35 patients who underwent open iliac

reconstruction between May 2005 and June – 2006. The study concluded that fast – track

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rehabilitation can safely be applied to patients undergoing conventional aorto – iliac

reconstruction. Early onset of oral nutrition and mobilization influence the fatigue in a

positive way21.

A study was carried out among 10 patients who had undergone abdominal aortic

aneurysm (AAA) open repair from May 2002 to May 2003. The aim of the study was to

determine the effectiveness of early ambulation after abdominal aortic surgery. The study

revealed that the early ambulation is safe and feasible. The post operative recovery could

be improved and the length of stay will be reduced by practicing early ambulation22.

A prospective cohort study was conducted among 50 patients who had undergone

abdominal hysterectomy from June 1, 2003 to December 31, 2003. The aim of the study

was to determine the safety and feasibility of early activity. The study concluded that

early activity is feasible and safe in hysterectomy patients. A majority of the patients

(78%) were able to ambulate 100 feet after 2 days of ambulation23.

A combined strategy of anesthetic and surgical care defines postoperative

rehabilitation, which aims to accelerate recovery from surgery, shorten convalescence,

and reduce postoperative morbidity. Preoperative and early postoperative oral feeding, a

relatively “dry “fluid regimen, and avoidance of or early removal of drain, gastric tubes

and bladder catheters all contribute of decreasing postoperative morbidity after

abdominal surgery. Postoperative pain control, prevention of nausea and vomiting,

shortening the duration of postoperative ileus, and early ambulation also will help to

decrease postoperative morbidity. The use of multimodal fast – track clinical

rehabilitation programs should improve outcomes and quality of life, reduce hospital

stays, and can save the money24.

6.3 STATEMENT OF PROBLEM:- “A QUASI EXPERIMENTAL STUDY TO EVALUATE THE

EFFECT OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE AND

ATTITUDE REGARDING EARLY AMBULATION AMONG CLIENTS

UNDERGOING ABDOMINAL SURGERY IN SELECTED HOSPITAL,

KOLAR.”

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6.4 OBJECTIVES OF STUDY:-

1. To assess the existing knowledge and attitude regarding the early

ambulation among the clients undergoing abdominal surgery in experimental

group and control group.

2. To assess the post test knowledge and attitude regarding the early ambulation

among the clients undergoing abdominal surgery in experimental group and

control group.

3. To assess the effectiveness of early ambulation on knowledge and attitude

regarding early ambulation among clients undergoing abdominal surgery between

experimental group and control group.

4. To correlate the knowledge and attitude regarding early ambulation among

clients undergoing major abdominal surgery in experimental group and control

group.

5. To associate the pre test knowledge and attitude regarding the early ambulation

among clients undergoing abdominal surgery with their selected demographic

variable in experimental group and control group.

6.5 HYPOTHESIS:-

H1 - There will be significant difference between the level of knowledge and

attitude regarding early ambulation among the clients undergoing major

abdominal surgery.

H2 – There will be a significant correlation between knowledge and attitude

regarding early ambulation among clients undergoing major abdominal surgery

with their selected demographic variable.

H3- There will be significant association of the mean knowledge score and

attitude score regarding early ambulation among clients undergoing major

abdominal surgery with their selected demographic variables.

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6.6 VARIABLES UNDER THE STUDY:-

Dependent variable:-

Knowledge and attitude regarding early ambulation among the clients undergoing

major abdominal surgery.

Independent variable:-

Self instructional module regarding early ambulation among the clients

undergoing major abdominal surgery.

Demographic variable:-

It includes the base line information of the client’s age, gender, religion,

education, family income, and type of surgery.

6.7 OPERATIONAL DEFINITION:-

Evaluate:-

It refers to the method of estimating and interpreting the effectiveness of self

instructional module regarding early ambulation among the clients undergoing

major abdominal surgery using knowledge questionnaire and attitude scale.

Effect:-

It refers to determining the extent to which the information in the self

instructional module has achieved the desired effect as expressed by gain in post-

test knowledge score.

Self instructional module:-

It refers to systematically structured self instructional module designed for clients

to provide information on early ambulation.

Knowledge:-

It refers to the awareness or understanding regarding early ambulation.

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Attitude:-

It refers the way of thinking or feeling expressed among clients undergoing

abdominal surgery.

Early ambulation:-

It is a technique in which client gets out of bed and engages in mild activities such

as sitting over bed, chair and light walking with or without assistance.

Major abdominal surgery:-

It refers to the surgery pertaining to the contents of the abdominal cavity, its walls

and orifices. In this study it includes herniorrhaphy, and appendectomy.

6.8 ASSUMPTIONS:-

1. Clients may not have adequate knowledge and attitude regarding early

ambulation.

2. Clients may shows response towards early ambulation.

3. Self instructional module may enhance the knowledge and attitude regarding early

ambulation.

4. Client’s level of knowledge regarding the early ambulation may vary with their

demographic variables

6.9 DELIMITATION:-

The study is delimited to selected clients who undergoing abdominal surgery at

selected hospital, Kolar.

7.0. MATERIALS AND METHODS.

7.1 SOURCES OF DATA:-

Data will be collected from clients who are undergoing abdominal surgery at

selected hospital Kolar.

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7.2 METHODS OF DATA COLLECTION:-Data will be collected by the investigator himself by using self instructional

module to assess the knowledge regarding early ambulation of clients undergoing

abdominal surgery.

7.2.1 RESEARCH APPROACH:-Evaluative research approach will be used to conduct the study.

7.2.2 RESEARCH METHOD AND DESIGN:-Quasi Experimental, non equivalent control group design.25

7.2.3 SETTING:-

The study will be conducted in the selected hospital, Kolar.

7.2.4 POPULATION:-The population for the study comprises of clients who are undergoing abdominal

surgery at selected hospital, Kolar.

7.2.5 SAMPLE SIZE:-The total samples of the study comprises of 50 clients.

Experimental group- 25

Control group-25

7.2.6 SAMPLING TECHNIQUE:-Non probability convenience sampling technique will be used for the proposed

study.26

7.2.7 CRITERIA FOR SELECTION OF THE SAMPLE:-Inclusion criteria:-

The study includes:-

1) Clients admitted for abdominal surgery.

2) Both male and female clients in between the age group 20-50 years.

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3) Clients who can understand English, Kannada.

Exclusion criteria:-

The study excludes:-

1) Clients who had undergone laparoscopic surgeries.

2) Clients who are not available at the time of data collection.

3) Clients who are in mechanical ventilator.

7.2.8 TOOL FOR DATA COLLECTION:-

The researcher will develop a structured questionnaire, which contain items on the

following aspects which are constructed in English and Kannada language:-

Section I- Demographic Performa:-

It consists of demographic variables such as Age, Sex, marital status, income,

occupation, education and type of surgery.

Section II - Structured questionnaire on knowledge:-

Structure questionnaire is used to assess the knowledge and attitude of clients

regarding early ambulation among clients undergoing abdominal surgery.

7.2.9 PERIOD OF DATA COLLECTION;-

The proposed period of data collection is 6 weeks.

7.2.10 METHOD OF DATA COLLECTION:-

Formal permission will be obtained from the concerned authority of selected hospitals,

to conduct the study. Informed consent will be taken from the samples and the samples

will be selected on the basis of selection criteria.

Phase 1 – Pre test will be conducted prior to major abdominal surgery to assess

the existing knowledge and attitude regarding the early ambulation among the clients

who are undergoing abdominal surgery using structured questionnaire.

Phase 2 – Self instructional module regarding the early ambulation among the

clients who are undergoing abdominal surgery will be given for 45 minutes.

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Phase 3 – After one week, post-test will be administered to assess the level of

knowledge on early ambulation to the same subjects with the help of same questionnaire.

7.2.11 DATA ANALYSIS METHOD:-

The collected data will be organized, tabulated and analyzed by using descriptive

statistics and inferential statistics.

a) Descriptive statistics - mean, median, mode, standard deviation, percentage

distribution will be used to assess the knowledge and attitude regarding early

ambulation among clients undergoing abdominal surgery.

b) Inferential statistics - Chi- square test will be used to associate between the pre

test knowledge and attitude regarding early ambulation among clients undergoing

major abdominal surgery27. Paired‘t’ test will be used to compare the pre test and

post test knowledge and attitude regarding early ambulation among clients

undergoing major abdominal surgery.

c) Projected outcome – After the pre-test, the investigator administers self

instructional module to the clients regarding early ambulation which will help

them to improve their health.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR

OTHER HUMANS OR ANIMALS?

No,

Non-invasive intervention will be done.

The client’s knowledge on early ambulation will be assessed using structured

knowledge questionnaire and self instructional module will be conducted for the

same group.

No other physical or laboratory procedures will be conducted or done on the

samples.

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7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes,

Ethical clearance has been obtained from the ethical committee of the college.

A written Permission will be obtained from the research committee of manasa

college of nursing, Malur.

Permission will be obtained from the authorities of the selected hospital kolar.

Informed consent will be obtained from the subjects enrolled for the study.

Confidentiality and anonymity will be maintained.

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8. LIST OF REFERENCES:-

1. Basic Nursing.7th Edition. Philadelphia: Lippincott Publishers; 1999.

2. Abdominal surgery, Available from: http://en.wikipedia.org Kingsley G, Scott IC.

Rehabilitation. Available from: http://www.thefreedictionary.com/rehabilitation.

3. Laura Browningi, Linda Denchy and Rebecca L Scholes. The quality of early upright

mobilization performed following upper abdominal surgery is low: an

observationalstudy.Availablefrom:http://www.ncbi.nlm.nih.govt/pubmed/21141230

4. Verolyn Rae Bolander. Sorensen and luckmann’s basic nursing a psycho

physiologic approach. 3rd edition. S A W.B Saunders company;1994.

5. Barbara Kozhier, Glenora ERB, Abdrey Berman, Shirlee J Synder. Fundamentals of

nursing –concepts, process and practice.7th edition..Delmer: Pearson Education

publications; 2005.

6. Caroline Bunker, Rosdahi. Textbook of /wiki/abdominal surgery.

7. Data monitor. Epidemiology: Major Abdominal Surgery - A key risk factor for deep

vein thrombosis and pulmonary embolism. Available from:

http://www.jstor.org/pss/4039921

8. Lewis Heitkemper, Dirksen O’Brien. Medical Surgical Nursing. 7th Edition. Missouri:

Elsevier; 2008

9. Joyce M Black, Jane Hawkins, Annabelle M Kane. Medical Surgical Nursing Clinical

Management for positive Outcome Vol 1. 6th Edition. New Delhi: WB Saunders

Publishers; 2001.

10. Richard W. Light and Ronald B. George. Incidence and significance of pleural

effusion after abdominal surgery. Available from:

http://chestjournal.chestpubs.org/content/69/5/621.

11. Frederick A. Anderson. Prevention of deep vein thrombosis and pulmonary embolism

in the perioperative period: a review. Available from:

http://www.jpma.org.pk/full_article_text.php?article_id=834.

12. Eliston Christ. Schwenam. Presuure ulcers and its

managemnthttp://www.haiwatch.com/upload/tools/H0277-0701-CI -pressure -

ulcer.pdf

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13. Lubawski J, Saclarides T. Postoperative ileus: strategies for reduction. Available

from: http://www.ncbi.nih.govt/pubmed items.”Lubawkis”

14. D U Das, Introduction to nursing care a comprehensive approach to nursing.4th

edition. India: W B Saunders Company; 2001.

15. Marjorie Mudge, L, E Hughes, Effectiveness of early upright mobilization after

abdominal surgery. Available from http://www.ncbi.nih.gov/pubmed/12434145

16. Massey RL, A randomized trial of rocking – chair motion on the effect of

postoperative ileus duration in patients with cancer recovering from abdominal

surgery.Available from http://www.ncbi.nlm.nih.govt/pubmed?term =early

%20%20ambulation%20in%20abdominal%20surgeries.

17. Potter and Perry. Fundamentals of Nursing. 6th Edition.philadelphia. Jaypee brother

medical publishers 2005.

18. G Delaney CP, Fazio VW, Senagore AJ. Postoperative management protocol for

patients with high co – morbidity undergoing complex abdominal and pelvic

colorectal surgery.Available from :http://www.annals.org/content /134/8 /637 .short.

19. Kurabe S, Ozawa T, Watanabe T, Aiba T. Efficacy and safety of postoperative early

mobilization after splenectomy in elderly patients. Available from:

http://www.ncbi.nlm.nih.govt/pubmed/20336332.

20. Carroll J, Alavi K, Pathogenesis and management of postoperative ileus, Available

from: http://www.ncbi.nih.govt pubmed/16575614

21. Lohr G, Keller H, Kutscher J, Huher R, Fast – tract rehabilitation after open aorta–

iliac vascular procedures. Available from: http://www.ncb i.nih.govt/pu bmed

/18702018.

22. Lohr G, Keller H, Kutscher J, Huher R. Fast – tract rehabilitation after open aorta–

iliacvascularprocedures.Availablefrom:http://www.ncbi.nih.Govt/pub med

/18702018.

23. Olsen PS, Schroeder T, Agerskov. Surgery for abdominal aneurysms. survey of 10

patients. Available from: http://www.ncbi.nih.govt/pubmed/1939327.

24. Bonnet F, Szymkiewicz o, Marret E. Rehabilitation after abdominal surgery,

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25. . Denise F Polit, Cheryl Tatano Beck. Nursing research generating and assessing

evidence for nursing practice. 9th Edition. India: Wolters Kluwer Publishers; 2011.

26. Suresh K Sharma. Nursing Research and statistics. 1st Edition. India: Elsevier

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27. P.S.S. Sundar Rao, J Richard. Introduction to biostatistics a manual for students in

health sciences. 2 nd Edition. New Delhi: Prentice – Hall of India; 2004.

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9. SIGNATURE OF THE

CANDIDATE

10.REMARKS OF THE

GUIDE

11.

NAME AND

DESIGNATION OF

GUIDE

11.1SIGNATURE OF

GUIDE

12.HEAD OF THE

DEPARTMENT

12.1 SIGNATURE OF HOD

13.

REMARKS OF

CHAIRMAN AND

PRINCIPAL

13.1SIGNATURE OF

PRINCIPAL

19