Rajiv Gandhi university of Health sciences, Karnataka

SYNOPSIS

FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. Name of the candidate MRS.ARADHANA KRISHNAN

Diana college of nursing,

Name of the Institution No.68,Chokkanahalli,

3. Course of study and subject Master of Science in Nursing

Medical Surgical Nursing

4. Date of admission to the course

5. Title of the topic A study to assess the effectiveness of oral

ice cubes over saline mouth wash on oral

mucositis among patients receiving

chemotherapy in selected oncology

hospitals,Bangalore .

1
6. Brief resume of the intended work

Introduction:

“Life is not measure by the breaths we take, but rather by the moments that take our

breath away.”1

Cancer refers to a large group of potentially lethal disorders characterized by abnormal cell

growth and metastasis .Because of its diversity and complexity, cancer has no single treatment

nor it can be attributed to a single etiologic agent. What is currently known about the disease

process, treatment options and methods of prevention changes virtually every day.2

In 1985, a goal of the National Cancer Institute was to reduce the cancer mortality by 50% by the

year 2000. Early detection is the best treatment for cancer. Cancer screening activities promote

early detection of malignancies and premalignant conditions and with early detection come the

greater likelihood of successful treatment. The diagnosis of cancer is a multiphasic process that

includes obtaining a careful history regarding host and environmental risk factors.2

An estimated 12, 84,900 persons were diagnosed with cancer in 2002. More than 8 million

Americans alive today have a history of cancer. It is estimated that 5, 47,000 Americans died of

cancer in 1995. Lung cancer is now the number one killer in both sexes.2

Each year American Cancer Society estimates the number of new cancer cases and deaths

expected in the U.S. in the current year, complies the most recent data on cancer incidence,

mortality and survival.3

2
A more systemic approach is necessary to truly affect a cure in many cases. In 1970s

chemotherapy was established as an effective treatment for cancer. The effect of chemotherapy is

at the cellular level. Chemotherapy disrupts the cell life cycle. The chemotherapeutic agents are

cytotoxic ie, they disable a cell which results in the cell death. As a result both malignant and

normal cells that are rapidly dividing will get affected.2

It is important to identify and differentiate between the toxic effects of the drugs and the

progression of the malignant process. Any side effects or adverse effects can be identified and

reported so that the drug dosage can be modified or discontinued.4 chemotherapy has got many

side effects. One of its side effects is infection. Infection is the leading cause of death in cancer

patients. Disruption of mucous membrane and skin induced by chemotherapy provides a locus

for infection. Oral complications frequently include mucositis, an inflammation of the oral

mucous surface and xerostomia or drying of the oral cavity. In chemotherapy, epithelial cells in

the oral mucosa slough and become denuded as a result of the cytotoxicity of chemotherapeutic

agents.2

Mucositis is often reported as the most debilitating side effects of cancer therapy. Hospitalization

is required in 16% of patients with mucositis. Mucositis can lead to septicaemia, bacteraemia and

fungemia when the patient is neutropenic. Earlier diagnosis could lead to a change in the

schedule of treatment and alleviating mucositis and its complications.5Thus assessing the nature

of mucositis becomes essential among patients receiving chemotherapy.

Chemotherapy- and radiotherapy-induced oral mucositis represents a therapeutic challenge

frequently encountered in cancer patients. This side effect causes significant morbidity and may

delay the treatment plan, as well as increase therapeutic expenses. Various topical mouth rinses

3
containing corticosteroids,disinfectants,antimicrobial substances,sucralfate,baking soda, or local

anaesthetics are used in the prophylaxis and therapy of chemotherapy or radiotherapy induced

oral mucositis. Various literatures support the use of many agents. In a study conducted the

author reported that saline rinses may be more effective than a regime using a more astringent

mouthwash.6

In an another study, it was reported that cryotherapy, or rapid cooling of the oral cavity using ice,

causes local vasoconstriction and hence reduces blood flow to the oral mucosa. Cryotherapy may

reduce the amount of drug reaching the oral mucous membranes, and may therefore reduce

mucositis caused by local cytotoxic activity of these drugs. Studies support the use of

cryotherapy as a cheap and effective method of minimising mucositis induced by bolus 5-

fluorouracil, but it is not effective for continuous infusions. However, the author concludes that

further work is needed to evaluate the effectiveness of this agent for chemotherapy-induced

mucositis.7

Keeping the above views in mind the investigator had an intense curiosity to evaluate the

effectiveness of oral ice cubes and saline mouth wash on prevention of oral mucositis among

patients receiving chemotherapy.

6.1. Need for the study

“Cancer does not define me, but how I live and fight with cancer DOES define

me.”

Cancer is a class of diseases characterized by out-of-control cell growth. There are over 100

different types of cancer, and each is classified by the type of cell that is initially affected.

Cancer is a group of more than 200 diseases characterized by uncontrolled and unregulated

4
growth of cells. An estimated 12, 84,900 persons were diagnosed with cancer in 2002. More than

8 million Americans alive today have a history of cancer. It is estimated that 5, 47,000

Americans died of cancer in 1995. Lung cancer is now the number one killer in both sexes.2

Each year American Cancer Society estimates the number of new cancer cases and deaths

expected in the U.S. in the current year, complies the most recent data on cancer incidence,

mortality and survival based on incidence data on cancer from National Cancer Institute, Centres

for Disease Control and Prevention, and the North American Association of Central Cancer

Registries and mortality data from the National Centre for Health Statistics.8

Cancer survival varies between countries. The CONCORD study provided the first opportunity

to estimate cancer survival in 11 states in USA covered by the National Program of Cancer

registries and the study covers the 42% of the US population. This was the first worldwide

analysis of cancer survival.9

Experts say that global cancer rates could increase by 50% to 15 million by 2020. In 2000, 5.3

million men and 4.7 million women died from cancer. It is said that 12.7 million cancer cases

and 7.6 million deaths occurred in 2008. It is estimated that about 9 million new cancer cases are

diagnosed every year and over 4.5 million people die from cancer each year in the world. 10

Researchers say that global burden of cancer continues to increase largely. WHO estimates that

84 million people will die of cancer between 2005 and 2015.11

The estimated number of new cancer in India per year is about 7 lakhs and over 3.5 lakh people

die of cancer each year.9 WHO says that India has one of the highest cancer rates in the world. It

indicates 10.6 per 1, 00,000 populations have cancer of gall bladder. It is the world’s highest

rate.12 In India the first report of cancer incidence was done in 1996-1998. A total number of

5
11,700 cases were registered. The most reported malignancies in males were lung cancer

(16.3%), cancer of oral cavity (7.1%), cancer of pharynx (5.7%), and larynx (5.7%). In females

frequently reported were breast cancer (22.7%), followed by cervical cancer (17.5%), gall

bladder (6.45), ovary (5.8%). This data provided information on cancer profile in eastern India.13

It is said that there would be about 1.5 lakh cancer cases at any given time in Karnataka and

about 35,000 new cases are added to this pool each year. Advanced Cancer Registry Program in

Bangalore used data from 105 hospitals and private clinics and it included more than 2, 00,000

patients with confirmed cancer. Among these rates of stomach cancer was high. And the Registry

also found a belt of Thyroid cancer in Karnataka.12

Increasing the intensity of radiation therapy and chemotherapy in the management of cancer has

increased the incidence of adverse effects, especially oral mucositis. The administration of many

chemo-radiotherapy regimens in patients with cancer may be complicated by toxicities that limit

the clinicians' abilities to deliver the most effective doses of active agents 14. Oral mucositis is a

major dose-limiting toxic effect and the most important cause of morbidity in patients

undergoing chemo-radiotherapy for head and neck cancers, in patients undergoing bone marrow

transplantation and those receiving certain chemotherapeutic agents for a variety of human

malignancies.15

The mouth is a frequent site of complications arising from drug or radiation cancer therapy, with

mucositis, xerostomia, osteoradionecrosis, and local infections being the most common. From

the stand-point of dose limitation, treatment breaks, quality of life, and health economic

outcomes, mucositis is the most significant acute oral toxicity. 16Oral mucositis is a frequently

occurring and debilitating complication of chemotherapy. It is said that 755 of patients

6
undergoing chemotherapy to treat cancer experience oral mucositis. Oral mucositis can lead to

malnutrition, fluid electrolyte imbalances, and other complications such as sepsis. Side effects

present a major barrier to the administration of doses sufficient to affect a cure. Many treatments

have already discussed regarding the management of this condition. Working knowledge of the

vast number of substances used for the treatment of oral mucositis is mandatory for health care

providers.17

Symptoms of mucositis vary from pain and discomfort to an inability to tolerate food and fluids.

Mucositis may also limit the patients’ ability to tolerate either chemotherapy or radiation. The

mucositis may affect patients’ gums and dental condition, speech, and self-esteem are reduced. It

is therefore extremely important that mucositis be prevented whenever possible or at least treated

to reduce its severity and possible complications.7

The intent of an article is to review preventive strategies and treatment approaches for patients

with established oral mucositis. Many agents of differing mechanisms of action have been used

in the prevention and treatment of oral mucositis induced by anticancer therapies. Currently, no

intervention is completely successful at preventing or treating oral mucositis. The several

solutions, drugs and methods used and studied in the prophylaxis and therapy of chemotherapy

or radiotherapy-induced oral mucositis reflects the need of new, more efficient tools in the

management of this complication. Current studies and our increasing understanding of the

etiology and pathogenesis of oral mucositis will lead to new approaches to the management and

improved quality of life for these patients.15

Further intensive research through well-structured clinical trials to obtain the best scientific

evidence over the standard therapy of oral mucositis is necessary to attain ideal parameters for

7
radiotherapy and chemotherapy.14 In a study conducted the effect of cryotherapy in prevention of

oral mucositis was evaluated. 60 patients were randomized, the experimental group (30) and the

control group (30). Oral mucositis in the patients was evaluated at 7, 14.and 21 days after

chemotherapy. They found that in experimental group receiving cryotherapy, oral mucositis was

not observed at 7 and 14 days. Similarly, incidence of oral mucositis in experimental group was

quite a bit lower when compared to the control group. 18

The above literatures and the investigators personal experience in the oncology unit motivated

the investigator to undertake this study. As ice cubes can be made readily available and cheaper,

people undergoing chemotherapy may effectively use this in their due course of therapy.

“Not everything that is faced can be changed. But nothing can be changed until it is faced.”

James Baldwin

6.2. Reviews of literature

Reviews can be categorized under following headings. They are;

A. Literatures related to chemotherapy induced oral mucositis.

B. Literatures related to the use of oral ice cubes on prevention of oral mucositis among patients

receiving chemotherapy.

C. Literatures related to the effectiveness of saline mouth wash on prevention of oral mucositis

among patients receiving chemotherapy.

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A) Literatures related to chemotherapy induced oral mucositis:

A study was done to assess the incidence and severity of chemotherapy-associated oral

mucositis. The study was done by a retrospective analysis of 150 patients with various solid

tumors. In addition, possible risk factors for the development of mucositis were identified.

Mucositis was scored using the World Health Organization (WHO) criteria. Eighty-seven

episodes of mucositis occurred in 47 (31%) patients. Twenty-six patients each experienced only

one episode, whereas 21 patients had up to eight episodes of mucositis. The 1,281 chemotherapy

cycles that have been analyzed included 87 cycles in which mucositis was observed. In 16

patients (11%) only slight oral mucosal changes were recorded (maximum WHO score 1), while

25 patients (17%) experienced mild to moderate mucositis (maximum WHO score 2), and in 6

patients (4%) mucositis was moderate to severe (maximum WHO score 3). No grade 4 mucositis

developed. The authors concluded that almost one-third of patients receiving chemotherapy for

solid tumors experienced one or more episodes of mild to more severe oral mucositis, indicating

that this is a frequent complication in such patients.19

An article on the occurrence of oral mucositis states that the oral and gastric mucosa is frequently

damaged during chemotherapy and leading to mucositis. Mucositis may require that subsequent

chemotherapy doses be reduced. Standard care for oral mucositis is based on effective oral

hygiene, appropriate analgesia, infection management and parenteral nutrition when needed. The

evaluation of new options to treat and prevent mucositis rather than control the symptoms is

therefore an urgent priority. Promising investigational approaches have recently emerged. This

includes fibroblast growth factor-20 and is being used in clinical studies.20

A study conducted was emphasizing mucositis as one of the most common adverse reactions

encountered in radiation therapy as well as in chemotherapy. Mucositis may limit the patients’

9
ability to tolerate chemotherapy or radiation and nutritional status is compromised. It may

drastically affect cancer treatment as well as patients’ quality of life. It is estimated that there is

40% incidence of mucositis in patients treated with standard chemotherapy.21

In a study conducted it revealed that the oral mucositis is a major dose –limiting toxic effect and

the most important cause of morbidity in patients undergoing chemotherapy. The intention of the

study was to review preventive strategies for patients with oral mucositis. Many agents of

different actions have been used and no interventions were completely successful at preventing

or treating oral mucositis.18

A review identified a vast number of interventions that have been investigated to determine their

effectiveness in the prevention or treatment of oral mucositis in cancer patients. The authors

report that further work is needed to evaluate the effectiveness of these agents for prevention of

chemotherapy induced oral mucositis.7

Cancer therapy induced oral mucositis is described as the most significant and debilitating acute

complication associated with radiation therapy and chemotherapy. Many strategies have been

evaluated to prevent oral mucositis, but the data is confusing since it is often conflicting. The

multifaceted process will probably be needed to optimize overall prevention.23

B) Literatures related to the effectiveness of oral ice cubes on prevention of oral mucositis

among patients receiving chemotherapy:

A study was conducted to compare the use of plain ice, flavoured ice and standard care to

evaluate the effect on mucositis and to determine patients’ perceptions of the two forms of oral

cryotherapy. Patients were randomized to receive each of the interventions across three cycles of

chemotherapy.-standard care alone, standard care plus plain ice, standard care plus flavoured ice.

Mucositis was assessed by the nurses prior to each of three chemotherapy cycles and 15 days

10
after each intervention. Two assessment tools were used, the Oral Assessment Guide and the

Western Consortium Cancer Nursing Research Scale. Participants completed a questionnaire to

determine their comfort and satisfaction with oral cryotherapy. Patients revealed that they used

standard care alone, they were more likely to experience symptoms of mucositis than when they

used either plain ice or flavoured ice. They concluded that both forms of cryotherapy were

effective in reducing the severity of oral mucositis after chemotherapy and were more effective

than standard care alone.24

Another study was conducted to investigate the effect of oral cryotherapy on the development of

chemotherapy induced mucositis in patients administered combined chemotherapy. Study

involved 60 patients, 30 of whom were in the study group and 30 in the control group. Ice cubes

at a size of that can be moved easily in the mouth and whose corners have been smoothed in

order that they will not cause irritation to in the mouth has been used in oral cryotherapy in the

study group. Oral cryotherapy was initiated five minutes before chemotherapy and maintained

during venous infusions of etoposide, platinol, mitomycin and vinblastine depending on the

chemotherapy course. The rate of mucositis in study group was 36.7% and control group was

90.0% and the difference was <0.05%. These findings have demonstrated that oral cryotherapy

makes an important contribution to the protection of oral health by reducing the mucositis.25

A study was conducted to evaluate the effect of cryotherapy in prevention of oral mucositis

associated with infusion of 5-fluorouracil (5-FU) with leucovorin. 60 patients were randomized,

the experimental group (30) and the control group (30). Oral mucositis in the patients was

evaluated at 7, 14.and 21 days after chemotherapy. They found that in experimental group

receiving cryotherapy, oral mucositis was not observed at 7 and 14 days. Similarly, incidence of

grades 1, 2 and 3 oral mucositis in experimental group was quite a bit lower when compared to

11
the control group. They concluded that oral cryotherapy has a significant contribution to the

protection of oral health by preventing oral mucositis.18

A study was done to assess the appropriate prevention and oral care in head and neck cancer

patients to provide the oral comfort and function for improving the patient’s quality of life.

Cryotherapy is useful in prevention of mucositis associated with short half-life stomatotoxic, 5-

FU. Patients are instructed to swish ice chips in their mouth for 30 minutes, beginning 5 minutes

before the administration of intravenous infusion. Ice chips producing local vasoconstriction and

decreasing blood flow to the oral mucosa and helps reducing chemotherapeutic drug exposure

and also the risk of mucositis.26

An experimental approach with Cross–over Design was done on prevention of mucositis among

cancer patients receiving 5-fluorouracil using plain versus flavoured ice cubes to care their pain

and improve their quality of life with fewer complications. The objectives of the study were to

assess the oral mucosa before and after the treatment, to identify the experiences of patients

during the therapy while sucking the ice cubes and compare the effectiveness of plain ice cubes

versus flavoured ice cubes in preventing oral mucositis. The check list scores of the patients

showed that there is a difference in the experience of the patients while sucking plain ice cubes

and flavoured ice cubes. As a whole the result showed that the flavoured ice cubes were effective

in preventing mucositis and the patients were in favour of the flavoured ice cubes.27

C) Literatures related to the effectiveness of saline mouth wash on prevention of oral

mucositis among patients receiving chemotherapy:

A study was done to review the current research evidence base for oral care procedures utilized

by nurses in order to identify best practice. Saline mouth washes widely advocated in the nursing

literature. Normal saline is not damaging to the oral mucosa and an isotonic solution (0.9%/v) is

12
recommended for mouth care. This study concluded that saline rinses may be effective than a

regime using a more astringent mouth wash.28

A study was conducted on effectiveness of mouth washes on prevention of oral mucositis.

Mucositis may be a painful, debilitating, dose-limiting side effect of both chemotherapy and

radiotherapy for which there is no widely accepted prophylaxis or effective treatment. The basis

of management is pain relief, prevention of dehydration and adequate nutrition. When tested

vigorously, most antiseptic mouth washes anti-ulcer agents were ineffective. Simple mechanical

cleansing by saline is the most effective measure.29

A randomized, controlled trial was designed using adult patients who were to have 50% or more

of the mouth irradiated as part of their treatment regimen for head and neck cancer. Forty

patients were assessed weekly during their course of radiotherapy using an oral assessment

guide. Twenty patients used normal saline rinses, and 20 used hydrogen peroxide. The patients

who received the normal saline rinses began advanced oral care than those received hydrogen

peroxide. Normal saline is also safe, economical and readily available.30

A study was conducted on effectiveness of commonly used mouth washes on prevention of oral

mucositis. Daily chlorhexidine mouth wash is often recommended for preventing chemotherapy

induced oral mucositis. Povidone iodine, NaCl 0.9% are also recommended. In this study three

out of five randomized controlled trials were included in a meta-analysis. The results failed to

detect any beneficial effects of chlorhexidine as compared with NaCl 0.9%.31

6.3 Statement of the problem

A study to assess the effectiveness of oral ice cubes over saline mouth wash on oral

mucositis among patients receiving chemotherapy in selected oncology hospitals,

Bangalore.

13
6.4 Objectives of the study

1. To assess the severity of oral mucositis among experimental group and control group.

2. To assess the effectiveness of oral ice cubes on severity of oral mucositis before and

after intervention among experimental group.

3. To assess the effectiveness of saline mouth wash on severity of oral mucositis before

and after intervention among control group.

4. To assess the effectiveness of oral ice cubes over saline mouth wash by comparing the

severity of oral mucositis between experimental group and control group after

intervention.

5. To find out the association between severity of oral mucositis among experimental

group after intervention and their selected demographic variables.

6. To find out the association between the severity of oral mucositis among control group

after intervention and their selected demographic variables.

6.5 Operational definitions

1. Assess- Refers to the statistical estimation of severity of oral mucositis among

patients receiving chemotherapy as determined by observation check list.

2. Effectiveness-Refers to the significant difference in the severity of oral mucositis

before and after the administration of oral ice cubes and saline mouth wash among

patients receiving chemotherapy.

14
 3. Ice cubes –Refers to the small, roughly cube-shaped chips of ice which is prepared

by the investigator domestically and these chips will be administered to the

experimental group, where they will be instructed to swish ice chips in their mouth

for 30 minutes beginning 5 minutes before the administration of chemotherapy.

4. Saline mouth wash- Refers to 0.9% normal saline and will be administered to the

control group where they will be instructed to rinse their mouth twice with 30 ml of

normal saline.

5. Oral mucositis- Refers to the inflammation of the oral mucous membrane as

list.

6. Patients receiving chemotherapy- Refers to both male and female clients who are
in the treatment of cancer with antineoplastic drugs in selected oncology hospitals,

Bangalore.

6.6 Hypothesis

H1: There is a significant difference in the severity of oral mucositis before and after

intervention among experimental group.

H2: There is a significant difference in the severity of oral mucositis before and after

intervention among the control group.

H3: There is a significant difference in the severity of oral mucositis between experimental

group and control group after intervention.

15
 H4: There is a significant association between severity of oral mucositis among

experimental group after intervention and their selected demographic variables.

H5: There is a significant association between the severity of oral mucositis among control

group after intervention and their selected demographic variables.

6.7 Assumptions

1. Patients receiving chemotherapy may have oral mucositis.

2. The use of oral ice cubes and saline mouth wash may have some effect on severity of oral

mucositis among patients receiving chemotherapy.

6.8 Limitations of the study

This study is limited to patients:-

 Both male and female.

 Who are in the age group of more than 18 years.

 Who are receiving chemotherapy in selected oncology hospitals, Bangalore.

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7. Materials and methods

7.1 Source of data Data will be collected from patients receiving

chemotherapy in selected oncology hospitals,

Bangalore.

7.2Method of data collection

Research design True Experimental design – Pretest-Posttest Basic

Experimental design

Setting Study will be conducted in selected oncology

hospitals, Bangalore.

Population Patients receiving chemotherapy.

Sample Patients receiving chemotherapy in selected

oncology hospitals, Bangalore.

Sample size 60 patients. Out of which 30 belongs to

experimental group and 30 belongs to control

group.

Sampling Technique Simple random sampling - lottery method will be

used to select the patients for experimental and

control group.

17
Inclusion criteria. The patients receiving chemotherapy :

 Who will be willing to participate in the

study.

 Who will be available at the time of data

collection.

Exclusion criteria The patients receiving chemotherapy:

 Who are undergoing radiation therapy.

 Who are suffering from head and neck

cancer.

 Who are in critical conditions.

Tool Tools will be divided into the following.

Section A.

 Structured questionnaire to assess the

socio-demographic data of the patients.

Section B.

 Observation check list to assess the

severity of oral mucositis in patients

receiving chemotherapy.

Section C.

 Oral ice cubes and saline mouth wash.

18
Data collection Prior to data collection, permission will be

obtained from the concerned authority and the

selected patients. After obtaining the consent

from the selected patients, data will be collected

by the researcher herself by using questionnaire

and observation check list.

Phase I

On the first day, socio demographic data will

be collected using structured questionnaire. The

severity of oral mucositis will be assessed in both

experimental and control group using the

observation check list.

Phase II

The researcher will then administer oral ice

cubes to the experimental group 5 minutes before

the administration of chemotherapy and instruct

them to keep it in the mouth for 30 minutes.

The control group will be given 30 ml of

0.9% normal saline in room temperature and will

be advised to rinse their mouth.

Phase III

The researcher will assess the

effectiveness of ice cubes on oral mucositis in

19
 experimental group and the effectiveness of

saline mouth wash on oral mucositis in the

control group using the observation check list.

Data analysis, and Data presentation The collected data will be organized by :

Descriptive statistics:

 Frequency distribution, percentage, Mean,

and standard deviation will be used to

assess the demographic variables.

Inferential statistics:

 Paired t-test will be used to compare the

severity of oral mucositis among

experimental and control group.

 Unpaired t-test will be used to compare

the severity of oral mucositis after the

intervention between the experimental and

control group.

 Chi-square test will be used to determine

the association between the severity of

oral mucositis among experimental and

control group after the intervention and

their selected demographic variables.

20
 Analyzed data will be presented in

the form of tables, diagrams, graphs based on

the findings.

7.3 Does the study require any investigations or interventions to be conducted on patients

or other humans or animals? If so, please describe briefly.

Yes. The study requires interventions to be conducted on patients receiving chemotherapy in

selected oncology hospitals in Bangalore.

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

Yes. Ethical clearance will be obtained from the ethical committee of Diana College of Nursing,

Bangalore. Permission will be obtained from the Principal, Diana College of Nursing, and

Bangalore. Permission will be obtained from the administrative heads of selected hospitals in

Bangalore. Informed consent will be signed by the participants of the study.

21
ETHICAL COMMITTEE

Title of the topic: A study to assess the effectiveness of oral

ice cubes over saline mouth wash on oral

mucositis among patients receiving

chemotherapy in selected oncology

hospitals, Bangalore.

Name of the candidate: Mrs. Aradhana Krishnan

Course and the subject: M.Sc., (N) 1st year.

Medical and Surgical Nursing specialty

Name of the guide: Prof. Vasantha Chitra. D

Head of the Department

Department of Medical Surgical Nursing

Diana College of Nursing,

Bangalore-6

Approved
Ethical committee

22
Members of Ethical committee

1. Prof. Veda Vivek

Principal and Head of the Department

Department of Community Health Nursing

Diana College of Nursing, Bangalore-64.

2. Prof. Elizabeth Dora

Head of the Department

Department of Child Health Nursing

Diana College of Nursing, Bangalore-64.

3 . Prof. Kalaivani. S

Head Of the Department

Department of Obstetrics and Gynecological Nursing

Diana College of Nursing, Bangalore-64.

4. Prof. Vasantha Chitra. D

Head of the Department

Department of Medical Surgical Nursing

Diana College of Nursing, Bangalore-64.

5. Prof. Rangappa

Biostatistician, GKVK,

Jakkur, International Airport Road,

Bangalore

23
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9.Signature of the candidate

The study selected is relevant and

researchable.
10.Remarks of the guide

Prof. Mrs. Vasantha Chitra

11.Name and designation of the Head of the Department

Diana College Of Nursing

Chokkanahalli, Hegde Nagar

Bangalore-64.

Signature

H.O.D Prof. Mrs. Vasantha Chitra

Head of the Department

Signature

12.Remarks of the Principal

forwarded for further action.

Signature

28