A DESCRIPTIVE STUDY TO “ASSESS THE KNOWLEDGE AND …



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|A DESCRIPTIVE STUDY TO “ASSESS THE KNOWLEDGE |

|AND PRACTICE TOWARDS THE CARDIO PULMONARY RESUSCITATION AMONG STAFF NURSES WORKING |

|IN CASUALITY IN A SELECTED HOSPITALS |

|AT TUMKUR (DIST).” |

|IN A VIEW TO DEVELOP SELF |

|INSTRUCTIONAL MODULE. |

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|PROFORMA FOR REGISTRATION OF SUBJECTS |

|FOR DESSERTATION |

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|Mrs. KANTHI MANI GARAPATI |

|MEDICAL – SURGICAL NURSING |

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|MADHUGIRI SRI RAGHAVENDRA COLLEGE OF NURSING |

|MADHUGIRI – 572132 TUMKUR DISTRICT |

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGLORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJRCTS FOR DISSERTATION

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|1. |NAME OF THE CANDIDATE |Mrs. KANTHI MANI GARAPATI |

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| |AND ADDRESS |M.Sc., Nursing 1st Year |

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| | |Madhugiri Sri .Raghavendra College Of Nursing, |

| | |Shankar Matt Road, |

| | |Raghavendra Extension, |

| | |Madhugiri – 572132, Tumkur district. |

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|2. |NAME OF THE INSTITUTION |Madhugiri Sri.Raghavendra College Of Nursing, |

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| | |Madhugiri. |

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|3. |COURSE OF STUDY AND SUBJECTS |M.Sc.,NURSING 1st Year |

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| | |Medical Surgical Nursing |

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|4. |DATE OF ADMISSION TO COURSE |25-5-2010. |

| | |A descriptive study to assess the knowledge and Practice towards |

|5. |TITLE OF THE TOPIC |Cardio Pulmonary Resuscitation among staff nurses working in |

| | |Casuality in a selected hospitals at Tumkur dist.In a view to |

| | |develop self instructional module. |

6. BRIEF RESUME OF INTENDED WORK:

INTRODUCTION:

Cardiopulmonary resuscitation (CPR) is an emergency procedure which is attempted in an effort to return life to a person in cardiac arrest. It is indicated in those who are unresponsive with no breathing or only gasps. It may be attempted both in and outside of a hospital.CPR involves chest compressions at a rate of at least 100 per minute in an effort to create artificial circulation by manually pumping blood through the heart. In addition the rescuer may provide breaths by either exhaling into their mouth or utilizing a device that pushes air into the lungs. The process of externally providing ventilation is termed artificial respiration.

An administering of an electric shock to the heart, termed defibrillation, is usually needed to restore a viable or "perfusing" heart rhythm. Defibrillation is only effective for certain heart rhythms, namely ventricular fibrillation or pulse less ventricular tachycardia, rather than asystolic or pulse less electrical activity. CPR may however induce a shockable rhythm. CPR is generally continued until the person regains return of spontaneous circulation (ROSC) or is declared dead CPR is indicated for any person who is unresponsive with no breathing or only gasps as breathing as it is most likely that they are in cardiac arrest. CPR training: CPR is being administrated while a second rescuer prepares for defibrillation.2

In 2010, the American Heart Association and International Liaison Committee on Resuscitation updated their CPR guidelines. The importance of high quality CPR (sufficient rate and depth without excessively ventilating) was emphasized. The order of interventions was changed for all age groups except newborns from airway, breathing, chest compressions (ABC) to chest compressions, airway, breathing (CAB).An exception to this recommendation is for those who are believed to be in a respiratory arrest (drowning, etc.)3

A universal compression to ventilation ratio of 30:2 is recommended for adult and in children and infant if only a single rescuer is present. If at least 2 rescuers are present a ratio of 15:2 is preferred in children and infants.In newborns a rate of 3:1 is recommended unless a cardiac cause is known in which case a 15:2 ratio is reasonable. If an advanced airway such as an endotracheal tube or laryngeal mask airway is in placed delivery of respirations should occur without pauses in compressions at a rate of 8-10 per minute. The recommended order of interventions is chest compressions, airway, breathing or CAB in most situations. With a compression rate of at least 100 per minute in all groups. Recommended compression depth in adults and children is about 5 cm (2 inches) and in infants it is 4 cm (1.5 inches. As of 2010 the Resuscitation Council (UK) still recommends ABC for children. As it can be difficult to determine the presence or absence of a pulse the pulse check has been removed for lay providers and should not be performed for more than 10 seconds by health care providers. 3

CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops, because permanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become dormant in as little as 4–6 minutes in an oxygen deprived environment and the cells are unable to survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with cardiac arrest intervals of 72±43 minutes, traditional methods achieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this new knowledge.4

In the 19th century, Doctor H. R. Silvester described a method (The Silvester Method) of artificial respiration in which the patient is laid on their back, and their arms are raised above their head to aid inhalation and then pressed against their chest to aid exhalation. The procedure is repeated sixteen times per minute. A second technique, called the Holger Neilson technique, described in the first edition of the Boy Scout Handbook in the United States in 1911, described a form of artificial respiration where the person was laid on their front, with their head to the side, resting on the palms of both hands. Upward pressure applied at the patient’s elbows raised the upper body while pressure on their back forced air into the lungs, essentially the Silvester Method with the patient flipped over. 3

6.1 NEED FOR STUDY

Over 750,000 citizens of the US and Europe suffer sudden cardiac arrest each year, and survival remains dismal: over 75% of victims do not leave the hospital alive.1,2 Cardiac arrest, requires treatment within minutes to attain survival. Cardiopulmonary resuscitation (CPR) and electrical defibrillation remain the two crucial interventions that can be life-saving during cardiac arrest. Through CPR training offered by the American Heart Association (AHA) and other organizations, laypersons can provide treatment to cardiac arrest victims before the arrival of emergency medical personnel. This review will summarize current knowledge about the importance of CPR in the treatment of cardiac arrest, and will describe several exciting new technologies that will make CPR more effective in coming years.3

A number of studies have confirmed that CPR can be life-saving when provided either by laypersons or medical professionals. In several large investigations, the prompt delivery of CPR served as a important predictor of survival—bystander CPR may almost double the chance of survival.5-7 Other work has shown that the probability of survival from cardiac arrest falls by 10–15% per minute without treatment, and well performed CPR likely shifts this curve towards higher probability of survival. Furthermore, recent investigations have suggested that CPR maintains the heart in a state favorable for defibrillation.8,9 That is, fatal cardiac arrhythmias common in cardiac arrest have a greater chance of being successfully terminated by electrical shock if CPR is performed first. A recent randomized trial in Norway suggested that in cases of prolonged cardiac arrest, delaying defibrillation in order to first provide several minutes of CPR significantly improved patient survival.10 Not only can prompt CPR make an important impact on outcomes, but the quality of CPR appears to matter greatly.5

Recent work has also shown that during actual human CPR, shallow chest compressions have an adverse impact on outcomes.9 Therefore, it is crucial that CPR be performed in accordance with published guidelines, which are formulated based on the best available data and updated every five years.3 Given the importance of CPR quality, it is perhaps surprising that the performance of CPR has only recently been assessed during actual cases of cardiac arrest. In a number of investigations over the past few years, CPR quality was found to be lacking during both in-hospital and out-of-hospital cardiac arrest, both in Europe and the US.11-15 In other words, poor CPR quality is endemic. In general, chest compressions are delivered too slowly and in too shallow a fashion, and ventilations are given too rapidly. There are several reasons why this might be the case despite the best intentions of providers. 3

First, CPR is deceptively simple to describe and remarkably difficult to perform, as humans generally do not have a good internal sense of timing to recognize 100 compressions or 8–12 ventilations per minute, and fatigue often prevents adequate depth efforts. Second, CPR is taught in the sterile conditions of a classroom, but performed in the volatile environment of a dramatically ill person surrounded by anxious onlookers—training can be easily forgotten in the panic of the moment, especially if that training has not taken place recently. It is clear from a variety of data that the majority of cardiac arrest patients do not receive CPR at all until the arrival of medical personnel precious minutes after the onset of arrest.

CPR training must be simplified and widely disseminated. Why, for example, can we not require CPR competence as a prerequisite for a driver’s license, or provide CPR training to every parent during the hospital stay before the birth of their child or before they leave the hospital with their newborn.3

Benjamin S Abella, MD, MPhil, is currently Assistant Professor of Emergency Medicine at the University of Chicago, where he also serves as Chair of the Hospital CPR Committee. Dr Abella maintains an active research program in cardiac arrest and resuscitation care, including clinical projects evaluating cardiopulmonary resuscitation (CPR) quality. Dr Abella is a recipient of research funding from the National Institutes of Health (NIH), Laerdal Medical Corporation and Philips Medical Systems, and has consulted on cardiac arrest topics for a variety of academic and commercial organizations. He will soon take a position at the University of Pennsylvania, where he will continue his clinical work and research as a member of the new Center for Resuscitation Science.3

The AHA has recently developed a product for the self-teaching of CPR in under 30 minutes called “CPR Anytime”, and such tools may make such ambitious training goals more feasible.CPR quality must also be improved. CPR is a crucial intervention that can improve outcomes from the highly mortal condition of sudden cardiac arrest. This intervention does not necessarily require special equipment and can be provided by laypersons and medical personnel alike. However, to be effective, CPR must be provided according to published performance guidelines. This is an exciting time for cardiac arrest care, as a body of important new research has led the way toward the development of novel tools to assist care providers in their attempt to save lives. 3■

6.2 REVIEW OF LITERATURE

6.2.1. A study was conducted to assess Attitudes toward the performance of bystander cardiopulmonary resuscitation in Japan. A sample size of a total of 4223 individuals (male 50%) completed the questionnaire, including high school students, teachers, emergency medical technicians , medical nurses, and medical students. The result shows that about 70% of the subjects had experienced CPR training more than once. Only 10-30% of high school students, teachers, and health care providers reported willingness to perform CC plus MMV, especially on a stranger or trauma victim. The study was concluded with most laypeople and health care providers are unlikely to perform CC plus MMV, especially on a stranger or trauma victim, but are more likely to perform CC only.6

6.2.2. A study was performed to assess Medical and nursing students' attitudes toward cardiopulmonary resuscitation and current practice guidelines. A pilot questionnaire concerning beliefs and attitudes toward CPR-D was distributed to 120 fourth year medical students and 120 nursing students. The result shows that questionnaire was answered by 71 of 120 fourth year students (59.1%), and 76 of 120 (63.3%) nursing students. Negative attitude toward defibrillation correlated with perceived organizational attitudes toward practice guidelines. The study was concluded with Medical students' attitudes mature as hoped for, but the nursing students need encouragement. More information is needed to diminish anxiety concerning defibrillation. Negative beliefs and attitudes toward defibrillation affect the students' attitudes toward practice guidelines.7

6.2.3. A study was conducted on Undergraduate nursing students' to investigate the extent to which Irish nursing students acquire and retain CPR cognitive knowledge and psychomotor skills following CPR training. Deterioration in both CPR knowledge and skills was found 10 weeks following CPR training. The result shows that the students' knowledge and skills were improved over their pre-training scores, which clearly indicated a positive retention in CPR cognitive knowledge and psychomotor skills. The study was concluded with findings present strong evidence to support the critical role of CPR training in ensuring that nursing student’s progress to competent and confident responders in the event of a cardiac related emergency.8

6.2.4. A study was performed on nurses' knowledge of and experience in cardiopulmonary resuscitation and on nurses' knowledge of the guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. A sample size of Three hundred and four nurses at Asahikawa Medical College Hospital were asked to fill in questionnaires. The results show that more than 80% of the nurses are much interested in CPR. Most of the nurses had received education and training in CPR as students or after graduation. The results of this survey demonstrate the need to provide more education (on CPR) to nursing staff.9

6.2.5. A survey was conducted on cardio-pulmonary resuscitation knowledge of the nursing staff in the .Asahikawa Medical College Hospital. A sample size of 66 nursing staffs on cardio-pulmonary resuscitation (CPR) and compared the results with that of 53 students of the Department of Nursing. The result shows that the "Ability" defined as an indicator of capability of practicing CPR of the nursing staffs was 17% and that of the student nurses was 0%. The study was concluded with that the CPR knowledge of both the nursing staffs and the student nurses was not sufficient, indicating the necessity of CPR education for both nursing staffs and student nurses.10

6.2.6. A study to examine the efficacy of self-instruction on nurses' competence. With a sample size of 20 undergraduate nursing students. The result shows that the self instructional was evaluated positively by the student nurses. The study was concluded with that CPR teaching methods need to be evaluated and refined in order to improve practice. 11

6.2.7. A descriptive and exploratory study was conducted to develop an educational practice of Problem-Based Learning in CPR/BLS with the sample size of 24 students in the third stage of the Nursing Undergraduate Course in a University in the Southern region of Brazil. The results showed that Problem – Based Learning allows the educator to evaluate the academic learning process in several dimensions, functioning as a motivating factor for both the educator and the student, because it allows the theoretical-practical integration in an integrated learning process.12

6.2.8. A cross sectional study was conducted to evaluate the knowledge of nurses on cardiopulmonary resuscitation. Nurses were assigned to groups 1 (33 nurses, in units equipped with a heart monitor and a cardiac defibrillator) and 2 (23 nurses, in units without this equipment). Nurses in group 1 showed better knowledge on the recognition of electrocardiographic recordings, and 91% of them recognized the ventricular fibrillation algorithm. Among nurses in group 2, 85% had knowledge on issues relative to basic care. The results showed that training in CPR generates positive results. The study was concluded with that Continued and systematic education strategies are essential to ensure better performance of the nursing team.13

6.2.9. This study was conducted to analyze the sustainable effects of cardiopulmonary resuscitation (CPR) reeducation on nurses' knowledge and skills. A experimental design was used for a single sample group of 47 nurses working for a general hospital. The result shows that Nurses' skills between the first and second time dropped but they improved between the second and third time owing to the effects of reeducation. The study was concluded with that reeducation of CPR clearly affects nurses' knowledge and skills.14

6.2.10. A study was performed to evaluate Hospital HCWs' attitudes towards Cardio pulmonary resuscitation (CPR) and ICU admission. A sample of 4903 health care workers including doctors, nurses of 5 Italian hospitals. The result shows that a great variation in responses among health care givers, depend on profession (RN/MD), on working area and experiential working characteristics. The study was concluded with importance of communication among HCW, in order to reach the best decision for every patient, and the great need of continuous educational programs which could compensate for lack of experience and help to create/maintain a strong bioethical and patient-oriented attitude.15

6.2.11. The study was conducted to assess the involvement of nurses in 'do not resuscitate’ decision-making on acute elder care wards and their adherence to such decisions in the case of an actual cardiopulmonary arrest. The result shows that 54.3% of respondents reported that cardiopulmonary resuscitation was 'never' started on their ward, 'rarely' on 39.5% and 'sometimes' on 6.2%. For patients without 'do not resuscitate' status, nurses started cardiopulmonary resuscitation 'rarely' or 'sometimes' on 22.2% of all wards, and 'often' or 'always' on 77.8%.the study was concluded with the need to make appropriate 'do not resuscitate' decisions and to avoid rash decision-making in cases of actual cardiopulmonary arrest, nurses should be involved early in 'do not resuscitate 'decision-making.16

6.2.12. A study was conducted to explore facets involved in the retention of the cognitive knowledge and psychomotor skills of cardiopulmonary resuscitation. A sample size of 73 RNs from three general hospitals. The result shows that cognitive knowledge was adequately retained but that skills were not. The study was concluded with need for certification as a CPR instructor, the number of years certified, and time since last certification were significantly related to skill scores. Findings prompt questions of appropriateness of the usual certification procedures for hospital-based RNs.17

6.2.13. The study was conducted to describe the basic cardiac life-support (BLS) skills of nurses and nursing students to assess the influence of resuscitation teaching and other group characteristics on performance. A study sample of 298 people (34 men and 264 women) .The results showed that 36% first assessed the patient's response, 67% opened the airway but only 3% determined pulse less ness before starting to resuscitate. Twenty-one percent of the participants compressed correctly for at least half of the test and 33%

Ventilated correctly at least half of the time. The study was concluded with the skills of the participants of the study cannot be considered adequate in terms of an adequate and prompt assessment of the need for resuscitation, and a 50% success rate in artificial ventilation and chest compression.18

6.2.14. A study was conducted to assess nurses' ability to initiate and maintain effective cardiopulmonary resuscitation in actual cardiac arrests. The results indicated that in the majority of cases nurses effectively managed all components of CPR. In particular the results suggest that nurses' actual management of cardiac arrests in a contextual environment differs markedly from results shown by research using simulated settings. The study was concluded with that the need for an evaluation of the use and effects of cognitive and metacognitive instructional strategies in CPR training courses on transfer of skills and knowledge to practice.19

STATEMENT OF THE PROBLEM

A descriptive study to “assess the knowledge and practices towards the Cardio Pulmonary Resuscitation among staff nurses working in Causality in a selected hospitals” at Tumkur Dist, in a view to develop an instructional module.

6.3 OBJECTIVES OF THE STUDY

1. To assess the knowledge of staff nurses regarding Cardio Pulmonary Resuscitation .

2. To assess the practice of Staff Nurses regarding Cardio Pulmonary Resuscitation .

3. To determine the association between the knowledge of Staff Nurses regarding Cardio Pulmonary Resuscitation with selected variables.

4. To develop an instructional module to correlate the knowledge and practice about Cardio Pulmonary Resuscitation.

6.4. VARIABLES UNDER STUDY:

Dependant : Knowledge, Practice.

Independent: Self Instructional Module.

Extraneous: Age, sex, education , experience, standards of educational institution, policies of hospital, attendance of professional development programme , availability of resources, exposure to mass media.

6.5. OPERATIONAL DEFINITIONS:

*ASSESSMENT To evaluate the knowledge and practice of CPR.

*KNOWLEDGE in this study “Knowledge” refers to the correct response from the respondent ( staff nurses who are working in Causalities) on CPR.

*PRACTICE In this study “Practice” refers to the actual application of knowledge and skills on CPR.

*C P R Cardiopulmonary resuscitation (CPR) is an Emergency procedure which is attempted in an effort to return to a person in cardiac arrest.

*CASUALTY A section of an institution that is staffed and equipped to provide rapid and varied emergency care, especially for those who are stricken with sudden and acute illness or who are the victims of severe trauma.

*STAFF NURSES A nurse is a healthcare professional who, in Collaboration with other members of a health care team, is responsible for: treatment, safety, and recovery of acutely or chronically ill individuals, health promotion and maintenance within families, communities and populations.

*HOSPITALS An institution that provides medical, surgical, or psychiatric care and treatment for the sick or the injured.

*INSTRUCTIONAL MODULE A self-contained instructional unit that includes one or more learning objectives, appropriate learning materials and methods, and associated criterion-reference measures.

6.6. ASSUMPTIONS:

6.6.1 Staff nurses who are not working in Casualties may have deficit knowledge regarding Cardio Pulmonary Resuscitation

6.6.2. Staff nurses who are not working in Casualties may have deficit practice regarding Cardio Pulmonary Resuscitation

6.6.3. Self instructional module will enhance the knowledge regarding Cardio Pulmonary Resuscitation.

6.6.4. Self instructional module will guide knowledge regarding assessment of a patient , need for CPR , to perform CPR in correctly on time.

7. MATERIALS AND METHODS:

The purpose of the study is to assess the knowledge and practices on CPR among staff nurses working in Casualties.

7.1. SOURCE OF DATA:

• Research approach : Descriptive approach

• Research design : Non experimental design

• Setting of the study : Selected hospitals at Tumkur dist

• Population : Staff nurses

• Sampling technique :Convenient sampling technique.

• Sample size : 100 staff nurses

• Sample criteria

*Inclusion criteria

- Nurses who are working in selected hospitals at Tumkur dist.

- Staff nurses who can understand Kannada and English.

- Staff nurses who are willing to participate in the study.

*Exclusive criteria

- Staff nurses who are not working in selected hospitals at Tumkur dist.

- Staff nurses who cannot understand Kannada and English.

- Staff nurses who are not willing to participate in the study.

7.2. METHOD OF DATA COLLECTION:

• Tools of data collection : structured questionnaire

Part A : Proforma for collecting the data on demographic Variables.

Part B : Sstructured questionnaire to assess the knowledge and practices on CPR.

• Data analysis and interpretation :

Data will be analyzed through descriptive and inferential method and statistics.

• Duration of the study – 6 weeks

• Does the study requires any investigations or interventions

-NO –

• Has ethical clearance has been obtained from your institution in case of the above.

Yes ethical clearance will be obtained from,

- The research committee of Madhugiri Sri Raghavendra College of Nursing.

- The authorities of selected communities, Madhugiri.

- The informed consent from the staff nurses who are willing to participate in this study.

8. LIST OF REFERENCES:

1. Suzanne C.Smeltzer, Brenda Bare, Text book of Medical – Surgical Nursing. Page no: 810-812.

2.. Lewis, Heikemper, etal. Text book of Medical – Surgical Nursing, assessment and management of clinical problems. Page no 1845 – 1849.

3. ,,popmed,medlife. Com.

4. B T Basavantappa, Text book of Medical – Surgical Nursing, Page no: 605-616.

5. A Journal of Nightingale Nursing Times, Volume -6,8; September 2010, Nov 2010.

6. Taniguchi T, Omi W, etal.“Department of Emergency and Critical Care Medicine” 2007 Oct;75(1):82-7. Epub 2007 Apr 8.

7. Niemi-Murola L, Mäkinen M,etal. Department of Anaesthesia and Intensive Care Medicine, 2007 Feb;72(2):257-63. Epub 2006 Nov 28.

8. Madden C.”Department of Nursing, Waterford Institute of Technology,” 2006 Apr;26(3):218-27. Epub 2005 Nov 28.

9. Masui. “Asahikawa Medical College Hospital” 2003 Apr;52(4):427-30.

10. Nagashima K, Suzuki A, Takahata O, Sengoku K, Fujimoto K, Yokohama H, Iwasaki H.”Department of Anesthesiology,” Asahikawa Medical College, Asahikawa 078-8510.

11. Davies N, Gould D. “Faculty of Health”, South Bank University, 103 Borough Road, London, 2000 May;9(3):400-10.

12. Sardo PM, Dal Sasso GT. Escola Superior de Saúde da Universidade de Aveiro (ESSUA),2008 Dec;42(4):784-92.

13. Bertoglio VM, Azzolin K,etal. Hospital Moinhos de Vento, Rio Grande do Sul, Brasil. 2008 Sep;29(3):454-60.

14. Oh SI, Han SS. Gyeonggi Provincial Medical Center Pocheon Hospital, 2008 Jun;38(3):383-92.

15. Zamperetti N, Mazzon D,etal. Department of Anesthesia and Intensive Care Medicine, 2007 Mar;73(3):119-27.

16. De Gendt C, Bilsen J,etal. End-of-Life Care Research Group, Vrije Universiteit Brussel, 2007 Feb;57(4):404-9.

17. Lewis FH, Kee CC,etal. 1993 Jul-Aug;24(4):174-9.

18. Nyman J, Sihvonen M. Helsinki Polytechnic, Tukholmankatu 10, 2000 Oct;47(2):179-84.

19. Boyde M, Wotton K. Princess Alexandra Hospital, Brisbane, 2001 Sep-Oct;17(5):248-55.

9. SIGNATURE OF THE CANDIDATE……………………………….

10. REMARKS OF THE GUIDE.

11. NAME AND DESIGNATION OF GUIDE.

11.1. SIGNATURE……………………………………………………

11.2. HEAD OF THE DEPARTMENT.

11.3. SIGNATURE……………………………………………………..

12. REMARKS OF THE CHAIRMAN / PRINCIPAL

12.1. SIGNATURE………………………………………………….....

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