RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Mr. LIJO JOSEPH

M.Sc. Nursing I year
Medical Surgical Nursing
Year 2010-2012

PADMASHREE INSTITUTE OF NURSING

KOMMAGATTA, BANGALORE

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 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Mr. Lijo joseph

NAME OF THE CANDIDATE 1st year M.Sc. nursing
1.
AND ADDRESS Padmashree Institute of Nursing
Bangalore.

NAME OF THE Padmashree Institute of Nursing

2.
INSTITUTION Bangalore.

COURSE OF THE STUDY 1st year M.Sc. nursing,

3.
AND SUBJECT Medical surgical nursing.

DATE OF ADMISSION TO
4. 2nd July 2010
THE COURSE

Effectiveness of application of water

gloves on pressure areas in management of
5. TITLE OF THE STUDY
bedsore among bed ridden patients in
selected hospital.

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6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

‘Pressure ulcers are red areas of sores on the skin.’ They are also called bed sores,
and decubitus ulcers. They can occur over any bony part of the body.
(Wound Care Communications Network)

Pressure ulcers are defined as areas of localized damage to the skin and underlying
tissue caused by pressure, shear, or friction. They are most common among patients who
are immobile, elderly, have no sensation in some area of their body, or in intensive care.

Dr. Koziak, who is considered to be the father of modern pressure sore research,
found that very high pressure over a short period of time was just as dangerous for
developing ulcers as low pressure over a longer period of time.1

Commonly known factors that increase the risk for developing pressure ulcers
include immobility, circulatory problems, infections, incontinence, passivity, and
decrease in consciousness. Sometimes pressure ulcers cause intolerable suffering for the
patient. They often are relapsing, painful, and represent a risk for secondary infection.
They may affect activities of daily living and social relations.2

Pressure ulcers develop when capillaries supplying the skin and subcutaneous
tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis.
Since 1930, researchers understood that normal blood pressure within capillaries ranges
from 20 to 40mm Hg; 32mm Hg is considered the average. Thus, keeping the external
pressure less than 32 mm Hg should be sufficient to prevent the development of pressure
ulcers.

However, capillary blood pressure may be less than 32 mm Hg in critically ill

patients due to hemodynamic instability and co morbid conditions; thus, even lower
applied pressures may be sufficient to induce ulceration in this group of patients. Pressure

2
ulcers can develop within 2 to 6 hours. Therefore, the key to preventing pressure ulcers is
to accurately identify at-risk individuals quickly, so that preventive measures may be
implemented. 3, 4
More than 100 risk factors of pressure ulcers have been identified in the literature.
Some physiological (intrinsic) and non physiological (extrinsic) risk factors that may
place adults at risk for pressure ulcer development include diabetes mellitus, peripheral
vascular disease, cerebral vascular accident, sepsis, and hypotension. A hypothesis exists
that these physiological risk factors place the patients at risk due to impairment of the
microcirculation system. 5
Microcirculation is controlled in part by sympathetic vasoconstrictor impulses
from the brain and secretions from localized endothelial cells. Since neural and
endothelial control of blood flow is impaired during an illness state, the patient may be
more susceptible to ischemic organ damage (e.g., pressure ulcers). Additional risk factors
that have been correlated with pressure ulcer development are age of 70 years and older,
current smoking history, dry skin, low body mass index, impaired mobility, altered
mental status (i.e., confusion), urinary and fecal incontinence, malnutrition, physical
restraints, malignancy, history of pressure ulcers, and white race.6
Preventing pressure ulcers has been a nursing concern for many years. In fact,
Florence Nightingale in 1859 wrote, “If he has a bedsore, it’s generally not the fault of
the disease, but of the nursing”. Others view pressure ulcers as a “visible mark of
caregiver sin” associated with poor or nonexistent nursing care. Many clinicians believe
that pressure ulcer development is not simply the fault of the nursing care, but rather a
failure of the entire heath care system—hence, a breakdown in the cooperation and skill
of the entire health care team (nurses, physicians, physical therapists, dietitians, etc.).7
Preventing pressure ulcers can be nursing intensive. The challenge is more
difficult when there is nursing staff turnover and shortages. The pressure ulcer
development can be directly affected by the number of registered nurses and time spent at
the bedside.

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 The use of support surfaces is an important consideration in pressure
redistribution. The concept of pressure redistribution has been embraced by the National
Pressure Ulcer Advisory Panel (NPUAP). “You can never remove all pressure for a
patient. If you reduce pressure on one body part, this will result in increased pressure
elsewhere on the body. Hence, the goal is to obtain the best pressure redistribution
possible.”8
The water gloves solves the problem by equally distribution of weight of the
pressure areas of patient body surface, and all pressure points contact the water at less
than capillary pressure. Thus capillary circulation continues unabated, nourishing even
tissue that over lies bony prominence.
The staging system is one method of summarizing certain characteristics of
pressure ulcers, including the extent of tissue damage. Hence, whether the nurse observes
the epidermis, dermis, fat, muscle, bone, or joint determines the stage of pressure ulcer.
The Christian Medical Society has divided support surfaces into three categories
for reimbursement purposes. Group 1 devices are those support surfaces that are static,
they do not require electricity. Eg. air, foam (convoluted and solid), gel, and water
overlays or mattresses. These devices are ideal when a patient is at low risk for pressure
ulcer development. Group 2 devices are powered by electricity or pump and are
considered dynamic in nature. Eg. Alternating and low-air-loss mattresses. Group 3
devices, also dynamic, comprises only air-fluidized beds. These beds are electric and
contain silicone-coated beads.These beds are used for patients at very high risk for
pressure ulcers.9
Most experts agree that when a pressure ulcer develops, its location, size (length,
width, and depth), and color of the wound; amount and type of exudates (serous, sangous,
pustular); odor; nature and frequency of pain if present (episodic or continuous); color
and type of tissue/character of the wound bed, including evidence of healing (e.g.,
granulation tissue) or necrosis (slough or eschar); and description of wound edges and
surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) should
be assessed and documented.

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6.2 NEED FOR THE STUDY

One of the largest studies regarding bed sores in a hospital setting was carried out
by the Agency for Healthcare Research and Quality. The report concluded that
hospitalizations for bed sores (also called decubitus ulcers, pressure ulcers, pressure
sores) have increased by more than 80% from 1993 to 2006. This increase includes
people who were admitted to the hospital because of pressure sores or developed them
while being treated for another condition in the hospital.

In 2006, there were 503,300 hospital stays with pressure ulcers noted as a
diagnosis–an increase of nearly 80% since 1993. The pressure ulcer stays totaled $11
billion in hospital costs. More than 90% of the pressure ulcer-related hospitalizations
were intended to be for medical conditions unrelated to pressure ulcer treatment.
Compared to stays for all other medical conditions, hospital stays related to pressure
ulcers were more often discharged to and long-term care facility and more likely to result
in death. 72% of adults hospitalized with a secondary pressure sore diagnosis were 65 or
older. In comparison 56.5% of adult patients had a principal diagnosis of pressure ulcers
were 65 or older.10

Bedsore develops when blood supply to the skin is cut off for more than two to
three hours. As the skin dies, the bed sore first started as a red painful area which
eventually turns purple. Left untreated the skin can break open and become infected. A
bed sore can become deep, extending into the muscles. Once bed sore is develops, it is
often very slow to heal.11

The reported incidence (number of new cases per year) of pressure ulcer in acute
care facilities ranges from 2.7% to 29.5 % the prevalence in acute care setting is ranges
from 3.5% to 29.5%.several population are at increased risk. Quadriplegic client, older
adults with femoral fractures, and client in critical care units have the highest risk.
Prevention of pressure ulcer begins with identifying the client risk. However all these
data shows the lack of quality care.

5
 Recurrence of pressure ulcer should be anticipated; therefore, active preventive
interventions are essential. The patients’ tolerance for sitting or lying on the healed
pressure area is increased gradually by increasing the time that pressure is allowed on the
area in 5-15 minute increments. Early recognition and intervention is essential to prevent
the unwanted problems.

A recent study by the Healthcare Management Council (HMC) found that US

hospitals stand to save millions of dollars per year by eliminating treatment quality errors.
According to the study, a 200 bed hospital is likely throwing away $2 million dollars
yearly because of bed sores, patient falls, and other never events and hospital acquired
conditions.12

One of the most important preventive measures for managing the bedsore is
decreasing mechanical load. If patients cannot adequately turn or reposition themselves,
this may lead to pressure ulcer development. It is critical for nurses to help reduce the
mechanical load for patients. The prevention of pressure ulcers represents a marker of
quality of care. Pressure ulcers are a major nurse-sensitive outcome. Hence, nursing care
has a major effect on pressure ulcer development and prevention. 13

Untreated bedsore can lead to serious complications. It is the responsibility of the

health care provider to prevent the bed sore in cost effective manner. Water gloves
application is the one of the best intervention which helps these health care providers to
manage the bedsore in an effective way.

Though it is not practiced in wide settings, use of water gloves to manage bedsore,
can reduce the cost of care although gloves are easily available in all settings. As people
are unaware of using gloves as cost effective and efficient method in managing the
bedsore. So the researcher chooses this study to propagate this intervention on a wide
spread in all health care settings.

The investigator personal experience with bed ridden patients strengthens the data
stated above. Investigator worked as a clinical instructor in a 150 bedded hospital, and

6
witnessed that all most all bed ridden patients frequently getting the complaints of bed
sore. And also the lack of availability of comfort devices and its high prizes increases the
chance for getting bedsore.

Once bedsore developed, it is difficult to cure. So interventions are very useful in

management of bedsore among bedridden patients not only in hospital settings and also
in community.

6.3 STATEMENT OF PROBLEM

A study to assess the effectiveness of application of water gloves on pressure areas

in management of bedsore among bed ridden patients in selected hospital, Bangalore.

6.4 OBJECTIVES

1. To assess the bedsore score among the bed ridden patients before application
of water gloves.
2. To assess the bedsore score among bed ridden patients after application of
water gloves.
3. To compare the pretest and posttest bedsore score among bedridden patients.
4. To associate the pretest bedsore score among bed ridden patient with their
selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

1. Effectiveness
It refers to the changes in skin condition on pressure area of bedsore which
is elicited through modified PUSH tool (pressure ulcer scale for healing).
2. Water Gloves
It refers to Un powdered rubber gloves filled with water to be kept on the
pressure area.
3. Pressure Area
It refers to the area around the bed sore.

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 4. Management
It refers to reduction of bed sore by using the application of water gloves.
5. Bed Sore
In this study bedsore refers to the changes in the skin on the pressure area,
this includes estimation of surface area of discoloration (erythema) of skin,
which is assessed by using the modified PUSH tool (pressure ulcer scale for
healing).
6. Bed Ridden Patients
It refers to the patients who are completely staying in the bed.

6.6 ASSUMPTIONS

1. Bed ridden patients may have high risk for occurrence of bedsore.
2. Water gloves application may reduce the worsening of bed sore.
3. Bedsore may vary with their selected demographic variables.

6.7 RESEARCH HYPOTHESIS

H1. There will be a significant difference between the mean pre test and post test
bedsore score among bed ridden patients.

H2. There will be a significant association between the pretest bedsore score
among bedridden patients with their selected demographic variables.

6.8 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 a topic and what are the
strength and weaknesses.

8
 A comparative study was conducted among one hundred sixty-two patients to
determine the effectiveness of two cushions in the prevention of heel pressure ulcers in a
geriatric population over 75 years of age. All patients were lying on a viscoelastic foam
mattress and were repositioned every 4 hours. The incidence of heel pressure ulcers
grades 2-4 was 1.9% in the wedge-shaped cushion group and was 10.2% in the pillow
group. The study provided evidence that a wedge-shaped, bedwide, viscoelastic foam
cushion decreased the risk of developing a heel pressure ulcer compared with the use of a
pillow.14

A prospective study was conducted to assess the risk of bedsore, included 100
patients from medical and surgical wards. Data were collected on admission, and subjects
were followed up at regular intervals. The Waterlow pressure ulcer risk assessment tool
was completed and patients were stratified "as not at risk," "at risk", "high risk", and
"very high risk".Out of 100 patients studied, 20% were at risk, 10% were assessed at high
risk, and 7% were classified as at very high risk for developing a pressure ulcer.
Necessary preventive measures were taken (posture change, specialized beds/mattresses,
nursing care, nutritional input, etc) for those patients at risk of development of pressure
ulcer. Four of 7 patients (57.1%) who were at very high-risk developed pressure ulcer as
compared with 2 of 10 patients (20%) categorized in the high-risk category within a
period of 2 weeks.15

A cross-sectional study was identified the prevalence of pressure ulcers among

elderly people living in long-stay institutions in Sao Paulo, Brazil. Demographic and
clinical data were collected in six long-stay institutions on two visits to each institution
between May and August 2007, during which all elderly patients with pressure ulcers
were evaluated. The Braden scale was used to identify the risk of developing pressure
ulcers and the National Pressure Ulcer Advisory Panel (NPUAP) stages for classifying
the pressure ulcers. Statistical analysis was performed using the chi-square test, Student's
t-test and Fisher's exact test. The population was 181 elderly people in May and 184 in
August: 23 had pressure ulcers in May (prevalence of 12.7%) and 17 in August

9
(prevalence of 9.2%). The mean age at the two times was 84 years, and the average
length of stay was 32 months. The prevalence of pressure ulcers was 10.95%.16

Two-phase non-experimental study was conducted to assess the pressure sore risk
on admission and discharge of critically ill patient. They were scored according to the
Waterlow system or the Stirling Pressure Sore Severity Scale. There was no significant
relationship between Waterlow score and mobilisation (χ2=3.2, DF=4, p=0.530) or
between Waterlow score and severity of sore (df=4, p=0.7265). The Waterlow Risk
Assessment Scale appears to be unreliable when used in clinical practice.17

A survey instrument was developed to capture experience, ease of use, and

perceived utility and weakness of the PUSH tool over 120 respondents, and samples are
collected through a convenience sample identified through the National Pressure Ulcer
Advisory Panel Web site as users or registered users of the PUSH tool. And study
concluded that PUSH easy to use and helpful in pressure ulcer management.18

A randomized controlled study was conducted over 40-50 samples to determine

differences between alternating pressure overlays and alternating pressure replacement
mattresses with respect to the development of new pressure ulcers. Patients were
randomized to either an alternating pressure overlay or an alternating pressure mattress
replacement. And study showed that there was no difference between alternating pressure
mattress replacements and overlays in terms of the proportion of patients developing new
pressure ulcers; however, alternating pressure mattress replacements are more likely to be
cost-saving.19

A prospective single blind randomized controlled clinical trial was used to

compare pressure ulcer outcomes in medial ICU patients nursed on either a reactive
mattress overlay or an active alternating pressure mattress. Patients included in the study
were those at high risk (Norton scale <8) or with a pressure on admission. The two
groups had similar patient characteristics. The progress of the ulcers showed significant
decreases in pressure ulcer surface area (p=0.05), total PUSH tool score (p=0.01). Study

10
suggested that 'active' alternating therapy is a useful adjunct in the care of highly
vulnerable patients, while the outcomes may be less favorable when using 'reactive',
constant low pressure devices.20

A comparative study was conducted to determine the effect of massage air bed in
preventing bedsore of critical patients. Critical patients lying in bed or with serious
difficulty in turning over were divided into two groups, the study group using massage air
bed, the control group using ordinary air bed. All the patients were kept clean and dry,
compared the effect of bedsore prevention in the two groups. Study showed that
prevention effect and turning interval of the two air bed is significant different (P0.05).
And study concluded that massage air bed is better than other methods to prevent
bedsore, which prolongs the turning interval and saves manpower, and is especially
practical on critical patients.21

A nursing study was conducted to assess the effect of changing position in

managing the bedsore among older adult. Researcher, divided older adults into three
turning treatment groups (every 2 to 3 hours [n = 32], every 4 hours [n = 27], or turned
two to four times/day [n = 41]) Researchers found that older adults turned every 2 to 3
hours had fewer ulcers. Study concluded that reducing the pressure on pressure points is
more effective in managing the pressure sore. This landmark nursing study created the
gold standard of turning patients at least every 2 hours.22

One randomized controlled trial that studied a small sample of 46 elderly patients
in the 30-degree-tilt position and the standard 90-degree side-lying position found no
significant difference in the development of pressure ulcers between the two group.23

In one prospective study, high-risk patients who were undernourished on

admission to the hospital were twice as likely to develop pressure ulcers as adequately
nourished patients (17 % and 9 %, respectively).24 In another study, 59 % of residents
were undernourished and 7.3 % were severely undernourished on admission to a long-
term care facility. Pressure ulcers occurred in 65 % of the severely undernourished
11
residents, while no pressure ulcers developed in the mild-to-moderately undernourished
or well-nourished residents. Study concluded that nutritional intake play vital role in
bedsore prevention.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from the bedridden patients.

7.2 METHODS OF DATA COLLECTION

i. Research design

Pre experimental one group pre test post test design.25

ii. Research variables

Dependent variable

Bedsore among bed ridden patients.

Independent variables

Application of water gloves.

Demographic variables

Age, sex, education, family income, duration of hospitalization, any use of

comfort devices, diagnosis.

iii. Setting

The study will be conducted in KCG hospital Bangalore.

iv. Population

The population of the study will comprise the entire bed ridden patients in KCG
hospital, Bangalore.

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 v. Sample

Patient who fulfills inclusion criteria and sample size is 60.

vi. Criteria for sample selection

Inclusion criteria

Study includes:-

1. Bed ridden patients above 18 years of age.

2. Patients who suffer from first degree of bed sore.

Exclusion criteria

Study excludes:-

1. Patients with restriction to change the position.

2. Patients with second degree and third degree bed sore.
3. Unconscious patients and patients in ventilator.
vii. Sampling technique

Non probability convenience sampling.25

viii. Tool for data collection

Section A

Demographic details consist of items on age, sex, education, family

income, duration of hospitalization, use of comfort devices, diagnosis.

Section B

Modified pressure ulcer scale for healing (PUSH tool), used to assess the
bedsore score before and after the application of water gloves.

ix. Procedure for data collection

After obtaining the required permission from the concerned authorities and
informed consent from the samples, the investigator will collect the data pertaining
to demographic variables. The study will be conducted in the following phases.

13
 Phase one

The investigator will assess the condition of bedsore before the application
of water gloves by using modified PUSH tool (pressure ulcer scale for healing).

Phase two

Water gloves will be applied in all the identified pressure area of the
bedsore among bed ridden patients. Water gloves will be applied continuous for
two hours, after which patients are allowed to change the position for two hours.
This will be repeated for four times a day and continuous for three days.

Phase three

After the end of the intervention (third day) the post test bed sore score will
be assessed by using modified PUSH tool (pressure ulcer scale for healing).

x. Plan for data analysis

The data collected will be analyzed by means of descriptive statistics and

inferential statistics.

Descriptive statistics

1. Frequency and percentage distribution will be used to describe

demographic variables.
2. Mean and standard deviation will be used to analyze the pretest and post
test bedsore score among bedridden patients.

Inferential statistic

1. Wilcoxon’s test will be used to compare the pre test & post test bedsore
score of bed ridden patients.
2. Chi-square test will be used to associate bed sore score among bed ridden
patients with selected demographic variables.25,26

14
xi. Projected outcome
Water gloves application can manage the bedsore of the bedridden patient
in a cost effective manner.

7.3 Does the study require any investigations or interventions to the

patients or human being or animals?

Yes, application of water gloves will be administered as intervention for bedridden

patient with bedsore.

7.4 Has ethical clearance been obtained from your institution?

Yes, permission will be obtained from the concerned authorities of selected

hospital and informed consent from the sample obtained. Confidentiality and
privacy of data will be maintained.

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8. LIST OF REFERENCES
1. http://www.aquilacorp.com/resources/pressure_sores.html

2. Mervi Lepisto, Elina Eriksson. Developing a Pressure Ulcer Risk Assessment

Scale for Patients in Long-Term Care. Issue 2; Volume 52: 18-22. Available
from: http://www.o-wm.com/article

3. Courtney H. Lyder, Elizabeth A. Ayello. Patient Safety and Quality-An Evidence-

Based Handbook for Nurses. Newyork: Lippincott Williamsand Wilkins;2003.

4. Kosiak M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil
2004; 40(2):62-9.

5. Lyder C, Preston, Ahearn D, et al. Medicare Quality Indicator System: Pressure

ulcer prediction and prevention module: final report. Bethesda, MD:
Qualidigm/U.S. Health Care Financing Administration; 1998.

6. Bliss MR. Hyperaemia. Tissue Viability 1998; 8:4-13.

7. Lyder C, Grady J, Mathur D, et al. Preventing pressure ulcers in Connecticut

hospitals using the plan-do-study-act model for quality improvement. Jt Comm J
Qual Patient Safety. 2004;30:205-14.

8. National Pressure Ulcer Advisory Panel Support Surface Standards Initiative;

2008 January. Available from URL http://www.npuap.org

9. D R Laub and R J Siegel. Use of water gloves. Available from

URL http://www.ncbi.nlm.nih.gov
10. Linda merana, Harrison hoker, Willin hock. Health care research and quality:
department of health publications 2003. Available from: URL
http://www.bedsorefaq.com
11. Corwin Brown. bed sore prevention and treatment of bedsore.2008 April 04.
Available from URL http://www.articlesbase.com
12. http://www.i-newswire.com/recent-study-shows-hospitals-lose/51947

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13. Elizabeth P. Tolmie, Lorraine N. Smith. A study of the prevention and
management of pressure sores. Inter nurses journal 2007 may 7; 6(2):114-20.
Available from: URL http://www.sciencedirect.com.

14. Heyneman A, Vander wee K, Grypdonck M. Effectiveness of two cushions in the

prevention of heel pressure ulcers. Worldviews Evidence Based Nurse. 2009
may7;6(2):114-20.

15. Shukla VK, Shukla D, Singh A, Tripathi AK, Jaiswal S, Basu S. Risk assessment
for pressure ulcer: a hospital-based study. J Wound Ostomy Continence Nurse.
2008 Jul-Aug; 4. Available from http://www.pubmed.com.
16. Chacon JM, Blanes L, Hochman B, Ferreira LM.Prevalence of pressure ulcers
among the elderly living in long-stay institutions. Sao Paulo Med J. 2009
Jul;127(4):211-5.

17. Paquay L, Verstraete S, Wouters R, Buntinx F, Van Gansbeke H. Implementation

of a guideline for pressure ulcer prevention in home care. Journal for Clinical
Nurses. 2010 Jul; 19 (13-14).

18. Berlowitz DR, Ratliff C, Cuddigan J, Rodeheaver GT. A study to determine the
perceived usefulness of the Pressure Ulcer Scale for Healing (PUSH). Adv Skin
Wound Care. 2005 Nov-Dec; 18(9):480-3.
19. Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K. Pressure relieving
support surfaces: a randomized evaluation. Health technol assess 2006; July 10
(22) .
20. Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J. A
randomized controlled trial comparing reactive air and active alternating pressure
mattresses in the prevention and treatment of pressure ulcers among medical ICU
patients. Journal Tissue Viability. 2010 Feb; 19 (1):7-15
21. Zhao Yuan,Gong Yi. Application of massage air bed in preventing bedsore of
critical patients. Journal for research: 2008 June 6.

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22. Norton D, McLaren R, Exton-Smith A. An investigation of geriatric nurse
problems in hospitals. Edinburgh UK: Churchill Livingston; 2005.
23. Seiler WO, Stahelm HB. Decubitus ulcer: preventive techniques for the elderly
patient. Geriatrics 2006; 40(7):53-60.
24. Thomas DR. Improving outcome of pressure ulcers with nutritional interventions:
a review of the evidence. Nutrition 2001; 17(2):121-25.

25. Polit F, Beck T. nursing research –generating and assessing evidence for nursing
practice.8th edition: Wolters Kluwer; 2008.

26. Barbara H. Statistical methods for health care research –inferential statistics.3rd
edition: lippincot; 1997.

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09. Signature of the candidate :

10. Remarks of the guide :

11.1 Name and designation of the guide : Mrs. PRASANNA .K

HOD & Associate Professor

11.2 Signature of the guide :

11.3 Co-guide (if any) : Mr. VENKATESAN.B

11.4 Signature of co-guide :

11.5 Head of the department : Mrs. PRASANNA.K

11.6 Signature :

12.1 Remarks of the principal :

12.2 Signature of the principal :

19