J.S.

S COLLEGE OF NURSING
ST
1 MAIN SARASWATHIPURAM, MYSORE

SYNOPSIS SUBMISSION

BY

JAYESH PAUL.E
ST
1 YEAR M.Sc NURSING
J.S.S COLLEGE OF NURSING
1ST MAIN, SARASWATHIPUREAM,
MYSORE-570009

GUIDE:

MRS. JANET MATHIAS

ASSISTANT PROFESSOR
MEDICAL SURGICAL DEPARTMENT
JSS COLLEGE OF NURSING
st
1 MAIN, SARASWATHIPURAM,
MYSORE-570009

BATCH: 2010-2012

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1
1. NAME OF THE CANDIDATE AND Mr. JAYESH PAUL.E
ADDRESS 1ST YEAR M.Sc (N)
( in block letters) J.S.S COLLEGE OF NURSING,
MYSORE.

2. NAME OF THE INSTITUTION J.S.S COLLEGE OF NURSING,

MYSORE.

3. COURSE OF STUDY AND SUBJECT 1ST YEAR M.Sc (N)

(MEDICAL SURGICAL NURSING)

4.
DATE OF ADMISSION OF THE 01-04-2010
COURSE

5. TITLE OF THE COURSE A STUDY TO ASSESS THE EFFECT OF

MUSIC THERAPY ON VITAL SIGNS AND
ANXIETY OF PATIENT UNDERGOING
HEMODIALYSIS IN SELECTED
HOSPITALS OF MYSORE

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6. BRIEF RESUME OF THE INTENDED WORK

6.0 INTRODUCTION

Music hath charms to soothe the savage breast,

to soften rocks, or bend a knotted oak."
-William Congreve

Kidney is an important organ of our body. The primary function of the kidney is to regulate
the volume and composition of extra cellular fluid (ECF) and excrete waste products. It helps in
maintaining the body in a healthy state. End stage renal disease (ESRD) is a slow progressive,
irreversible distruction of functional unit of kidney caused by inherited disorder, prolonged medical
condition such as diabetic mellitus and hypertension or long term use of certain medication.1

Chronic kidney disease (CKD) and end stage renal disease (ESRD) are emerging public
health problems in developing countries. A survey was conducted to estimate the ESRD incidence
among 572029 subjects residing in 36 wards of the Bhopal city. The average crude and age-adjusted
incidence rates were 151 and 232 per million populations respectively. The mean age was 47 years
and 58% of them were males. They also found that the commonest cause of ESRD was Diabetic
nephropathy (44%) .2

Kidney transplantation and hemodialysis are the only choices of treatment for ESRD and
CKD patients. Transplantation is a good choice as it can relive the patients entire problem with
ESRD, but it is not possible for every patient due to the shortage of suitable donors, increased
incidence of organ transplant rejection, age and ill health of many ESRD patients. Hence, most of the
patient prefer and have to depend on hemodialysis for survival.1

Hemodialysis is the procedure to remove waste and excess fluid from the blood when the
kidney cannot do so sufficiently through the process of diffusion, osmosis and ultrafiltration using
external dialyser1. Studies have revealed that, about one million people are undergoing
hemodialysis world wide3. In hemodialysis patient there may be a chance for developing
complications. Complications are divided in to acute complication and chronic complications.

Acute complications occur during routine hemodialysis treatment. They include hypotension,
back pain, itching, chills and fever. Some research studies found that, the treatments for these
complications are more effective when they are treated with a combination of pharmacological
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treatment and an alternative/complimentory therapy. Among these therapies, the most commonly
used therapies are music therapy, aroma therapy, imagery therapy and massage. Among which music
therapy has a predominant effect on hemodialysis patients.4

Music is universal and connects across language barriers. Most people can respond to music
in some way regardless of illness or disability. Music has an inherent ability to generate an emotional
response in the listener. It stimulates a relaxation response which can therefore lead to physiological
changes in the body. Music is known to reduce stress thereby producing related benefits such as
lower blood pressure, improved respiration, reduced heart rate, better cardiac performance and
reduced tension in muscles.5

Music therapy uses music to promote positive changes in the wellbeing of an individual.
These positive changes may be manifested as changes in physical development, social and
interpersonal development, emotional or spiritual wellbeing or cognitive abilities.5

Some research studies have proved that, music have the effect to elevate the level of
melatonin, epinephrine and norephiniphrine in the alzheimers patient. These are the chemicals which
act on the brain to control mood, depression and sleep. The benefits of the therapy were still evident
even six week after cessation of the therapy and in case of the melatonin the effect persist even
longer.5

Music therapy is gaining wider acceptance in the general medical community and has
certainly stood the test of time. Music therapists are now found practicing in a variety of institutions
dealing with mental health, developmental and early intervention programs, correctional institutions
and special education programs. Many are having success where traditional treatment methods have
failed4. Nursing profession in the present era can imbibe the technique and improve patient comfort
in varied settings where procedures are prolonged and frequent.

6.1 NEED FOR THE STUDY

Chronic kidney disease (CKD) is a global threat to health in general and for developing
countries in particular, because therapy is expensive and life-long. Over 1 million people worldwide
are alive on dialysis or with a functioning graft. Incidence of CKD has doubled in the last 15 years.
In USA, 30 million people suffer from CKD. The study also revealed that the incidence of chronic
renal failure is high in India.3

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 Research studies have shown that, nearly 7.85 million people in India are affected by chronic
renal disease. Aetiologically, diabetes (41%), hypertension (22%), chronic glomerular nephritis
(16%), chronic interstitial disease (5.4%), ischaemic nephropathy (5.4%), obstructive uropathy
(2.7%), miscellaneous (2.7%) and unknown cause (5.4%) are the major causes.3

Hemodialysis is a prolonged procedure lasting for 3-5 hours. According to a research study,
the acute complications commonly occur during routine hemodialysis treatments include,
hypotension (25 to 55%); cramps ( 5 to 20%); nausea and vomiting ( 5 to 15%) ; headache (5%) ;
chest pain (2 to 5%); back pain ( 2 to 5%) ; itching (5%); fever and chills ( Less than 1%) .1

The people who are undergoing heamodialysis may develop anxiety. Anxiety, an emotion
characterized by feelings of apprehension and helplessness, is nearly always present in people
undergoing medical procedures. Most patients would prefer to relieve anxiety because of the
psychological discomfort it causes. The medical professionals are aware of the physiological
complications of anxiety. Anxiety is known to cause increased blood pressure, heart rate and
respiration rate, all of which lead to poor circulation, and can cause fluctuations in body temperature,
urinary urgency, enlarged pupils, and loss of appetite .It has been found that anxiety leads to
increased cortisol levels, which inhibit the immune system and blood clotting. Lastly, conditions that
arouse anxiety increase pain. Thus, it is always a challenge to care providers to keep anxiety at a
minimum for patients comfort and safety.

An experimental study to determine the effectiveness of music therapy on anxiety among the
post-operative ambulatory patients was conducted in a post operative setting. The sample consisted
of 42 ambulatory surgery patients in both experimental and control group. The patients in the
experimental group were allowed to listen to the music of their choice along with the standard pre-
operative instructions. The heart rate, blood pressure, respiratory rate were used as parameters to
measure anxiety and physical stress. The results revealed that the patient in the experimental group
showed significantly lower heart rate and greater improvements in blood pressure and respiratory
rate compared to control group. Hence, it was concluded that music therapy yields demonstrable
benefits and was recommended for patients in various ambulatory surgical settings7.

The research studies found that music has an inherent ability to generate an emotional
response in the listener. It stimulates a relaxation response which can therefore lead to physiological
changes in the body. Music is known to reduce anxiety thereby producing related benefits such as
lower blood pressure, improved respiration, reduced heart rate and better cardiac performance 6.

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Though many research studies have been conducted abroad on effect of music therapy on various
physiological and psychological parameters of patients but in India no much published literature
could be retrieved. Hence, the researcher felt the need to determine the effect of music therapy on
hemodialysis patients in Indian scenario, so that the evidence can be generated which can be adopted
as complementary therapy to reduce the suffering of these clients.

6.2 REVIEW OF LITERATURE

1. Incidence of chronic renal failure and hemodialysis.

A prospective study involving 48 centres distributed all over India was conducted for the
period of 1-3 months. Data comprised of prospective investigation conducted on 4145 CKD patients
in various health centres. The results revealed the etiological patterns as follows; diabetes (29.7%),
chronic glomerulonephritis (19.3%), hypertension (14%), chronic interstitial disease and vesico-
ureteral reflux (12.6%), obstruction and calculus (9.3%), ADPKD and Alport Syndrome (8.4%),
undiagnosed (6.2%). Based on the result of the study the prevalence of CRF in India is 0.8%.
Diabetes had emerged as most frequent (30-40%) cause followed by hypertension (14-22%)3.

A population screening study was conducted in Delhi, India to determine the prevalence of
chronic renal failure among adults. The researcher used a multi-stage cluster sampling method in the
south zone of Delhi. The data was collected through questionnaires, physical examination, urine test
for albumin, sugar and blood test for serum creatinine. The researcher selected a sample of 4712
people with mean age of 32 years and 56.16% were males. Among them, 37 were found to have
CRF. Thus, the researcher concluded that, the prevalence of CRF in that population was 0.78% or in
other words, if it is estimated for total Indian population, it is around 7.85 million people.8

A survey was conducted to determine the incidence of acute renal failure (ARF) and related
risk of death among hospitalized medicare beneficiaries. The result revealed that, the incidence of
ARF among elderly medicare patients increased steadily. i.e, about 11% per year. Patients with ARF
were at significantly at higher risk of death than those with other diagnoses. Approximately 15% of
patients with ARF died in the hospital compared to 5% of those with other diagnoses. The mortality
rate was even higher (33%) for patients with ARF as a secondary diagnosis. It was also found that,
about 5.6 million patient got discharged with ARF between 1988 to 2002, and approximately
600,000 among them with severe ARF required dialysis to replace the lost kidney function. The
overall incidence of ARF was quadrupled from 1988 to 2002, while the rate of ARF patient requiring
dialysis increased by more than 6 times9.

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 2. Effectiveness of music therapy on anxiety and vital signs in hemodialysis patients.

An experimental study was conducted to determine the effects of music therapy on anxiety
and depression in patients undergoing hemodialysis. A non equivalent control group pre test post
test design was used. They selected 36 samples (experimental group-18; control group-18) who
received hemodialysis in three different hospitals .The data was collected through music preference
questionnaire (MPQ), anxiety measurement, and depression measurement. The results revealed that
the experimental group had less anxiety scores than the control group (F=8.05, p=0.008) and the
experimental group had less depression than the control group (F=11.86, p=0.002). It was concluded
that, music therapy may be applied as a method of nursing intervention contributing to the
improvement of quality of life by reducing the anxiety and depression of patients undergoing
hemodialysis10.

A study was conducted to evaluate the effects of music therapy on stress, anxiety, depression,
immune function and vital signs among patient undergoing hemodialysis. A quasi experimental pre
test post test non equivalent control group design was used with a sample of 47 patients. The
experimental group received music therapy for four weeks i.e. 3 hours per each session, three times a
week. The results revealed that, music therapy decreased stress, anxiety and depression; increased
the number of B lymphocytes and decreased diastolic pressure significantly among experimental
group compared to control group11.
An experimental study determined the influence of musical rhythms on the perception of subjective states of mind of adult patients on hemodialysis. The

researcher selected 43 patients who were undergoing hemodialysis. The patients were divided in to four groups. The first group received music therapy on Monday and

Wednesday morning, second group on Monday and Wednesday afternoon, third group on Tuesday and Thursday morning and the fourth group on Tuesday and Thursday

afternoon for two weeks and researcher used march and waltz music styles. The subjects states of mind were evaluated immediately, before and after the intervention. The

results revealed that 80% of the patients felt that time went by faster after the intervention in both rhythms. Hence, it was concluded that, music therapy was widely accepted

by patients irrespective of the specific rhythms12

An experimental study to determine the effects of preferred music listening on anxiety and
pain perception in patient undergoing hemodialysis.. They selected a sample of 60 patients
(experimental group-30; control group-30) who were undergoing hemodialysis. They administered
music therapy only for the experimental group during hemodialysis. The anxiety and pain of both
groups were measured before and after the hemodialysis. The results of the study showed that, the
experimental group had less anxiety and pain than the control group13.

An experimental study was conducted to determine the effect of music therapy in reducing the
amount of fluctuation in the blood pressure of patients undergoing hemodialysis treatment. The
samples were adult patients undergoing hemodialysis who were between the ages of 22 and 81. The

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control group received blood pressure measurement after each hour of dialysis. The experimental
group received the same blood pressure measurement but received music prior and after the
treatment. The statistical tests revealed no significant difference between the groups. However, the
results were statistically significant for every blood pressure reading. Therefore, the researcher
concluded that, the experimental group displayed less anxiety upon entering the treatment room,
suggesting that the opportunity to listen to music reduced their anxiety14.

An experimental study to determine the effect of live music on the reduction of negative side
effects experienced by pediatric patients during the onset, final 30 minutes of hemodialysis treatment
and removal of needle was conducted among five subjects in a pediatric hemodialysis unit. An
ABAB reversal design was utilized with A being baseline (no music during hemodialysis) and B
being live music intervention during cannulation of vascular access, the last 30 minutes of
hemodialysis treatment, and needle removal. Due to the small sample size only mean scores were
tabulated and no statistical tests were applied. The results revealed that, there was a decrease in pain
and anxiety behaviour when music intervention were implemented in all three phase of treatment and
the blood pressure fluctuations were not influenced by the music therapy15.

An experimental study to determine the effect of music therapy on stress and qulity of life
among patients undergoing hemodialysis was conducted using a non-equalent control group pre-test
post-test design. The study sample consisted of 21 patients who received hemodialysis in two
different hospitals. The 14 received treatment in one hospital were assigned to the experimental group
and the 7 in other hospital to the control group. The data were gathered through questionnaires and
physiological measurements. The music therapy was provided to the experimental group during the
hemodialysis and control group received the routine care. The results revealed that the post test
diastolic blood pressure of the experimental group (t=3.14, p=0.0064) was less than the control
group. There was no difference between the two groups on the pre-test, post- test psychological stress
scores or the depression scores and there was no significant difference in the pre-test and post-test
quality of life score between the two groups. Hence, it was concluded that, music therapy was
effective in maintaining the blood pressure and the statistical tests were not significant because of the
less sample size16.

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6.3 STATEMENT OF THE PROBLEM

A study to assess the effect of music therapy on vital signs and anxiety of patients undergoing
hemodialysis in selected hospitals of Mysore.

6.4 OBJECTIVES

The objectives of the study are:

1) To assess and compare the vital signs among patients undergoing hemodialysis before,
during and after the administration of music therapy.

2) To assess and compare the level of anxiety among patients undergoing hemodialysis before,
during and after the administration of music therapy.

3) To determine the relationship between vital signs and anxiety of patients undergoing
hemodialysis before, during and after the administration of music therapy.

4) To find the association of level of vital signs and anxiety of hemodialysis patients with their
selected personal variables viz. Age, gender, education, occupation, income, duration of
illness, number of hemodialsis cycle undergone, availability of information booklet on
management of ESRD and dialysis, any previous alternative therapy or educational section
attended for reducing the adverse impact of hemodialysis.

6.4.1 CONCEPTUAL/ THEORETICAL FRAMEWORK

Conceptual framework based on Kings goal attainment theory.

6.4.2 OPERATIONAL DEFINITION

Effect- Effect is the change caused by somebody or something 17. In this study, effect refers to the
change which will occur in the vital signs and levels of anxiety of patient undergoing hemodialysis
as a result of music therapy. The desired change is the reduction in values of vital signs and level of
anxiety.

Music Therapy- Music therapy is a form of sound therapy, uses the universal appeal of rhythmic
sound to communicate, relax, encourage healing, and create a general feeling of well-being. It can
take the form of creating music, singing, moving to music, or just listening 4. In this study, music
therapy refers to listening to slow and soft instrumental music played on CD player and listen
through use of headphones which will be provided to the patient undergoing hemodialysis procedure
in the following pattern. one cycle before, two cycles with a gap of 20 minutes interval during the
procedure and one cycle half an hour before the end of the procedure for duration of 30 minutes
each cycle; At the end of 20 minutes interval after each cycle vital signs and level of anxiety will be
measured.

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Vital signs- Vital signs refers to temperature, pulse, respiration and blood pressure which are
indispensible indicators of a persons current state of health 18. In this study vital signs refer to
recording the temperature, pulse rate, respiratory rate and blood pressure initially, and at the end of
each music therapy cycle.

Temperature Temperature refers to the difference between the amount of heat produced by the
body processes and the amount of heat lost to the external environment. The normal body
temperature is 37 degree Celsius or 98.6 Fahrenheit19.

Pulse The pulse refers to the palpable bounding of blood flow noted at the various points on the
body. It is an indicator of circulatory status. The normal range of pulse is 60 to 100 beats per
minute19.

Respiration- Respiration refers to the mechanism the body uses to exchange gases between the
atmosphere and the blood and the blood and the cells, It involves ventilation, diffusion and perfusion.
Normal range of respiration is 12 to 20 breaths per minutes19.

Blood pressure Blood pressure refers to the lateral force on the walls of an artery by the pulsing
blood under pressure from the heart. The normal Blood pressure is 120/80 mm of Hg19.

Anxiety- Anxiety is defined as the state feeling nervous, worrying about something 17. In this study, it
refers to the feeling nervous or worry about the outcomes of hemodialysis, the patient is undergoing
which is measured by STAI-S and expressed in terms of anxiety scores.

Haemodialysis Hemodialysis refers to a procedure to remove waste materials and excess fluid from
the blood when the kidney cannot do so sufficiently through the process of diffusion, osmosis and
ultra filtration by using external dialyser, which requires transporting blood from the patient through
a dialyser and return of filtered blood to the patient. The entire cycle lasts for 3-5 hours and usually
done thrice weekly1.

Patients undergoing hemodialysis- Patient undergoing hemodialysis refers to the adult patients
aged between 18 to 60 years, who are adviced to undergo hemodialysis and are on regular
hemodialysis in the given setting.

6.5 HYPOTHESES

The following hypotheses are stated and will be tested at 0.05 level of significance.

H1- The mean post-test vital signs score of patients undergoing haemodialysis who received
music therapy will be significantly lesser than the mean post test vital signs score of those who did
not receive music therapy.

H2- The mean post-test anxiety score of patients undergoing hemodialysis who received music
therapy will be significantly lesser than the mean post test anxiety scores of those who did not
receive the music therapy.

H3- The mean post-test vital signs score of patients undergoing hemodialysis will be significantly
lesser than their mean pre test vital signs score..

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H4- The mean post-test anxiety scores of patient undergoing haemodialysis will be significantly
lesser than their mean pre test score anxiety scores.

H5- There will be significant relationship between vital signs and anxiety of patients undergoing
hemodialysis before, during and after the administration of music therapy.

H6- The level of vital signs and anxiety of patients undergoing haemodialysis will have significant
association with their selected personal variables viz age, gender, education, occupation,
income, duration of illness, number of hemodialsis cycle undergone, availability of information
booklet on management of ESRD and dialysis, any previous alternative therapy or educational
section attended for reducing the adverse impact of hemodialysis.

6.6 ASSUMPTION

The assumptions of this study are:

1. Hemodialysis procedure will have impact on patients physiological and psychological status
which may be exhibited in terms of fluctuations in their vital signs and feeling worried about
their health and outcome of procedure.

2. Listening to slow instrumental music will calm the mind and promotes relaxation.

3. The prolonged duration of the procedure promotes patients willingness to seek a therapy to
reduce his feeling of nervousness.

6.7 DELIMITATIONS

Study is delimited to:

1. Administration of music therapy only for the duration of half an hour, one cycle before, two
cycles with gap of 20 minutes during and one cycle before the end of the hemodialysis
procedure.

2. The administration of selected slow and soft instrumental music played on CD player.

7.0 MATERIAL AND METHODS:

RESEARCH DESIGN AND APPROACH

Quasi experimental- non-equivalent control group pre test-post test design

E O1 X O2

C O1 - O2

KEY

E - Experimental group
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C - Control group
O1- Pre-test
O2- Post-test
X Music therapy

SCHEMATIC REPRESENTATION OF RESEARCH DESIGN

GROUPS Pre Intervention Intervention Post Intervention

Experimental group Base line assessment Administration of Assessment of vital
of vital signs and music therapy as per signs and anxiety;
anxiety of patients the plan mentioned in
undergoing operational First assessment
hemodialysis half an definition. After 20 minutes of
hour before the starting of
hemodialysis hemodialysis
procedure. procedure.

Second assessment
After 1 hour 10
minutes of starting
the hemodialysis
procedure.

Third assessment
After 2 hours of
starting the
hemodialysis
procedure.

Fourth assessment
After 20 minutes of
completion of
hemodialysis
procedure.

Control group Base line assessment Routine care Assessment of vital

of vital signs and signs and anxiety;
anxiety of patients
undergoing First assessment
hemodialysis half an After 20 minutes of
hour before the starting of
hemodialysis hemodialysis
procedure. procedure.

Second assessment

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 After 1 hour 10
minutes of starting
the hemodialysis
procedure.

Third assessment
After 2 hours of
starting the
hemodialysis
procedure.

Fourth assessment
After 20 minutes of
completion of
hemodialysis
procedure.

VARIABLES OF THE STUDY

Independent variable: Music therapy

Dependent variables : Pulse, Temperature, Respiration, Blood pressure and Anxiety.

Extraneous variables: Selected personal variables viz age, gender, education, occupation, duration
of illness, number of hemodialysis cycle undergone, availability of information booklet on
management of ESRD and dialysis, any previous alternative therapy or educational section attended
for reducing the adverse impact of hemodialysis.

7.1 SOURCE OF DATA

Setting : Dialysis units of selected hospitals of Mysore

Population : Adult patients undergoing hemodialysis in selected hospitals of Mysore

7.2 METHOD OF COLLECTION OF DATA

SAMPLE AND SAMPLING CRITERIA

INCLUSION CRITERIA

Patients undergoing hemodialysis:

Who are aged between 18 to 60 years.

Who are willing to participate.
EXCLUSION CRITERIA

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Patients undergoing hemodialysis:

Having hypotension/ bradycardia/ high or sub normal temperature/ bradypnea.

SAMPLING TECHNIQUE: Non-probability purposive sampling

SAMPLE SIZE: 60 patients undergoing haemodialysis, 30 patients in experimental group receiving

music therapy during hemodialysis, 30 patients in control group.

METHOD OF DATA COLLECTION:

Approval from authority.

Select sample as per criteria and obtain informed consent.
Assign patients to be either in control group, or to experimental group.
Administer music therapy as per research design
Check vital signs and anxiety as per research design.

PLAN OF DATA ANALYSIS:

Descriptive statistical analysis.

Frequency and percentage will be used to describe the sample characteristics. Frequency,
percentage, mean, median, standard deviation and range will be computed to analyse vital signs and
anxiety scores.

Inferential statistical analysis

Paired t test to compare the mean vital signs and anxiety scores with in the group.

Independent t test to compare the mean score of vital signs and anxiety between the group.

ANOVA to compare the significance of variance among the group.

Chi squire to determine the association of selected personal variables with level of vital signs
and anxiety of patients undergoing hemodialysis.

7.3 Does the study requires any investigation or intervention to be conducted on patients or
other humans or animals? If so, please describe briefly.

Yes, administering music therapy on patients undergoing hemodialysis.

7.4 Has ethical clearance been obtained from your institution in case of 7.3

Yes

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3. Suresh Chandra, Sanjay Agarwal. Incidence of chronic kidney disease in India. Oxford
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8. Sanjay Kumar Agarwal, Suresh Chand Dash, Mohammed Irshad, Sreebhuasn Raju, Ravinder
Sing, Ravinder Mohan Pandey. Prevalance of chronic renal failure in adults in Delhi, India
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9. Jay L Xue, Sushrut S Waiker. While incidence of acute renal failurerises, Risk of death
declines. Journel Of The AMERICAN Society Nephrology 2006; Feb 28.

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11. Kim KB, Lee MH. Sok SR. The effect of music therapy on anxiety and depression in
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12. Leandro Bechert Caminha, Maria Julia Paes da Slva, Eliseth Ribeiro Leao. The influence of
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13. M Pothoulaki, RAR Macdonald, P Flowers, E Stamataki, V Filiopoulos, D Stamatiadis, et al.
An investigation of the effects of music on anxiety and pain perception in patients
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9.0 SIGNATURE OF THE CANDIDATE:

10.0 REMARKS OF THE GUIDE:

11.0 NAME AND DESIGNATION OF GUIDE (in block letters)

MRS. JANET MATHIAS
ASSISTANT PROFESSOR
MEDICAL SURGICAL DEPARTMENT
JSS COLLEGE OF NURSING 1st MAIN, SARASWATHIPURAM,
MYSORE.

11.2 SIGNATURE:

HEAD OF THE MEDICAL SURGICAL NURSING DEPARTMENT

DR. BHARTI.M
PRINCIPAL
J.S.S COLLEGE OF NURSING, I MAIN, SARASWATHIPURAM,
MYSORE.

11.4 SIGNATURE

17
REMARKS OF THE CHAIRMAN AND PRINCIPAL:

DR. BHARTI. M.
PROFESSOR AND PRINCIPAL
J.S.S COLLEGE OF NURSING, I MAIN, SARASWATHIPURAM,
MYSORE.

12.2 SIGNATURE

18