1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1 NAME OF THE CANDIDATE & JAIN K PAUL

ADDRESS
MSc NURSING I YEAR

ST.JOHNS COLLEGE OF NURSING

BANGALORE-560 034

2 NAME OF THE INSTITUTION ST.JOHNS COLLEGE OF NURSING

3 COURSE OF STUDY & SUBJECT MASTERS DEGREE IN NURSING

MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION 02.05.2009

5 TITLE OF THE TOPIC

EFFECTIVENESS OF AROMATHERAPY ON PAIN AMONG POST-

OPERATIVE PATIENTS IN ORTHOPAEDIC WARD IN A SELECTED

HOSPITAL, BANGALORE.
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6. BRIEF RESUME OF THE INTENDED WORK

6.1. Need for study

Pain is a universal, complex, subjective experience. It is the most common reason

for a client to seek medical care, and the number one reason for a person to take

medication. Pain is an unpleasant sensory and emotional experience associated with

actual or potential tissue damage1.

Pain is a major economic problem and a major cause of disability that hampers

the lives of many people. There is overwhelming evidence that pain was under treated in

the hospitals. In the last decade alone, numerous studies have continued to prove that pain

is still not adequately treated in all areas of health care. Inadequate pain management can

lead to many consequences affecting the client or family physiologically, emotionally and

financially to greatly impair quality of life1.

A study on influence of expectations and actual pain experiences on satisfaction

with post-operative pain management showed that patients commonly expect moderate to

severe pain in the post-operative period and that the actual pain experience is mainly in

accordance with the individuals pre-operative expectations2.

Surgeries are associated with more severe, steady wound pain and the pain on

movement in the post-operative period demanding good post-operative pain management.

Bone pain related to orthopaedic surgery is more intense than muscle splitting and

stretching procedures of other surgeries1.

Approximately 5 Million Indians undergo Orthopaedic Surgery and they suffer

acute pain related to surgery3. Pain management, therefore has received increased
 3

attention with the movement toward patients rights and the advent of more sophisticated

means for delivery of pain medication. Type and site of surgery are predictors of severity

and duration of acute pain. There are many ways to manage pain in the post-surgical

client, which include pharmacological and non-pharmacological techniques 4. The Joint

Commission on Accreditation of Health Care Organisations (JCAHO) has also mentioned

the importance of practical use of non-pharmacologic interventions5.

Cognitive behavioural measures to relieve pain have been popular for years

mainly as adjuncts to drug therapy. Effectiveness of these measures is attributed to the

Gate Control Theory. These measures include distraction, imagery, relaxation, hypnosis,

massage, music therapy, aromatherapy, prayer and meditation 1. Among the various

measures aromatherapy has been gaining popularity as a simple and easy administrative

mode of alternative therapy for, not only pain but also insomnia, anxiety, depression,

headache, nervous tension, hypo tension, cardiac regulation, integumentary disorders,

sinusitis and infections6.

Aromatherapy is one of the fastest growing areas in complementary therapies.

Modern interest in aromatherapy was initiated in France in 1930s. Clinical

Aromatherapy is defined as the use of essential oils for their expected outcomes that are

measurable1. Evidence shows that this was first used by the Chinese, centuries ago to

enhance their well-being while Egyptians used it for cosmetic, fragrant, medicinal and

spiritual purposes. Studies have shown that it stimulates the immune system, strengthens

your resistance and helps to fight against certain diseases. It can also improve blood

circulation and lymphatic drainage, and so it can also be used to treat a cut or a minor

burn7.
 4

Potential uses of aromatherapy in the management of acute postoperative pain

was explored by using Lavender essential oil and it showed that there is pain relief

among the patients who were in the experimental group8.

Experts speculate that our sense of smell plays a very important role among other

senses. That means it is incredibly powerful, about 10,000 times stronger than other

senses. Aromatherapy uses this power of smell in a wide range of settings-from health

spas to hospitals-to treat a variety of conditions. In general it appears to ease pain,

enhance mood and promote a sense of relaxation. Several clinical studies suggest that

essential oils (particularly Rose, Lavender and Frankincense) administered to pregnant

woman by qualified midwives lowered feelings of anxiety and fear, promoted a sense of

well-being and reduced the need for pain medications during delivery7.

In India, the use of aromatherapy and olfactory research is still in its infancy.

Even though India has been famous for botanical medicines from time immemorial, now

its use is restricted only to Ayurvedic clinics, Naturopathy clinics, Beauty therapy and

Holistic Health Centres. It is rarely used in hospital settings. A study done in St. Johns

Medical College Hospital, Bangalore to assess the effectiveness of aromatherapy on

physiological & psychological components of relaxation among orthopaedic clients also

recommended to explore its effect on pain9.

Investigators own experience is that the clients undergoing orthopaedic surgery

have severe pain and the wellbeing and comfort using analgesics in these patients is

limited. The constant use of Analgesics has shown to have several adverse effects,

including dependence syndrome among patients. Complementary therapies like

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aromatherapy can help to reduce pain, thereby reducing the use of Analgesics and

maintain wellbeing in the clients.

Considering all the facts described above, the researcher felt that there is a strong

need to incorporate aromatherapy into the nursing practice. So, the researcher has

intended to study the effect of aromatherapy on pain reduction among post-operative

orthopaedic clients in St. Johns Medical College Hospital, Bangalore.

6.2. Review of Literature

A literature review involves the systematic identification, location, scrutiny and

summary of written materials that contain information or a research problem10.

The investigator has organized the related literature under the following headings

after reviewing various research studies and non research literature.

Studies related to post-operative pain perception

Studies related to post-operative pain management

Studies related to aromatherapy

Studies related to post-operative pain perception

The influence of expectations and actual pain experiences on satisfaction with

postoperative pain management was done at Sahlgrenska University Hospital, Sweden. A

random sample of 191 surgical patients responded to pre- and post-operative

questionnaires. It was found that 53% of patients with previous surgical experience

claimed to have moderate or severe pain post-operatively. Most patients (91%) expected
 6

pain of moderate to severe intensity and among them 76% reported to have such pain

levels, 81% were satisfied with pain management while only 8% were dissatisfied3.

A qualitative study to explore patients expectations and experiences of pain and

factors contributing to effective or ineffective management of pain was done among 10

patients in a mixed surgical ward at a District General Hospital in the South England.

Pain scores were obtained using a visual analogue scale preoperatively and a taped in-

depth interview was done on fifth postoperative day. The results showed that patients

expected moderate to severe pain after surgery, but the intensity of the pain experienced

was significantly greater than anticipated11.

Studies related to post-operative pain management

A randomized, double-blind and controlled clinical trial regarding efficacy of pre-

emptive analgesia for postoperative pain relief in lumbo-sacral spine surgeries was done

in Ganga Hospital, Coimbatore. Sample size of 82 patients, were randomized to the

control (n=40) and to the study group (n=40). Pain was quantified using visual analogue

scale (VAS) and verbal rating scale (VRS) post-operatively. Data were analyzed by

Mann-Whitney test. VAS and VRS values at all time intervals were significantly lower in

the study group as compared with the control group. There was also a significant delay in

the first demand for supplemental analgesics in the post-operative period in the study

group12.

The economics, resource use and patient satisfaction regarding postoperative

analgesia were observed among patients after total abdominal hysterectomy (TAH), total

hip (THR) and knee replacement (TKR) surgery at New England Medical Centre,
 7

Boston. Enrolment of 30 patients was based on a convenient sampling method. Data were

collected regarding pain intensity using 0-10 point scale and American Pain Society

Quality Improvement Patient Outcome Questionnaire; and regarding costs and resource

use for services provided by hospital using current financial tracking software. All

analysis was done by mean and standard deviation. The results showed that the main pain

scores were 3.4, 2.7, and 2.0 among TAH, THR and TKR patients respectively. The most

commonly reported adverse effects were abdominal pain (3.8) and dry mouth (3.1) for the

TAH group, whereas insomnia (3.0) and dry mouth (3.0) were the most frequently

reported adverse effects among THR and TKR groups respectively13.

Effectiveness of effleurage back massage on physiological (B.P, Heart Rate &

Respiratory Rate) and psychological (pain & anxiety levels) components of relaxation

was assessed among 60 clients who are confined to bed in orthopaedic ward at St. Johns

Medical College Hospital, Bangalore. The study used one group pre-test post-test design.

Data were collected using structured interview for baseline information, record of

physiological parameters, visual analogue scale and state trait anxiety inventory. The data

was analyzed by range, mean, standard deviation, paired t test, Mann Whitney test,

Kruskal Wallis test, RMANOVA with Pillars trace and Pearsons product moment

correlation coefficient correlation. The study showed a significant change in

physiological and psychological parameters of relaxation. The mean pain level at pre-

massage was 4.4 which reduced to 2.8 after massage14.

A pilot study on effectiveness of auricular acupuncture (AA) for pain relief after

ambulatory knee arthroscopy (AKA) was done among 20 patients who were selected

randomly before AKA at Ernst Moritz Arndt University, Germany. Pain intensity was
 8

assessed on VAS before acupuncture, on discharge from recovery room and during the

follow up examination. Heart rate and blood pressure were recorded before and after AA

procedure, and just before discharge. Statistical analysis was performed using unpaired

Students t-test, Mann-Whiteney test and Chi-square test. The results showed that

Ibuprofen consumption after surgery in the AA group was lower than in the control

group, pain intensity on 100 mm VAS and other parameters were similar in both groups.

Thus, it showed that AA might be useful in reducing postoperative analgesic requirement

after AKA15.

Studies related to aromatherapy

A small scale qualitative study of 6 nurses and midwives who had undertaken a

diploma in aromatherapy in order to find out what changes they had made in their clinical

practice was done in UK. The sample had completed the aromatherapy course between 9

months and 2 years previously. Data were collected using interview which were tape-

recorded and generally lasted for about 40 minutes. Data were analysed using the

procedure outlined by Colaisse and significant statements were clustered into themes.

The findings showed that aromatherapy for treating clients was concentrated mainly on

the effects of massage and the moisturising effect of oil and the practice is mostly

restricted because of limitation of policy or protocol in the institutions16.

A study to assess effectiveness of aromatherapy using lavender essential oil on

physiological and psychological components among 55 orthopaedic clients was done at

St. Johns Medical College Hospital, Bangalore. The study used one group pre-test post-

test design and samples were selected using purposive sampling technique. Data were
 9

collected using interview schedule (baseline information), record of physiological

parameters, state trait anxiety inventory, perceived stress scale and relaxation rating scale.

Data were analyzed using range, mean, standard deviation, paired t test, Students t-test,

Mann Whitney test, Kruskal Wallis test, RMANOVA with Pillars trace and Pearsons

product moment correlation coefficient correlation. Results showed that there was a

significant reduction in physiological and psychological parameters following

aromatherapy9.

The use of aromatherapy with hospice patients to decrease pain, anxiety and

depression and to promote an increased sense of wellbeing was done in Las Vegas, USA.

The study measured the responses of 17 cancer hospice patients on three different days

consisting of no treatment (control); water humidification (control); or 3% lavender

aromatherapy. Vital signs as well as levels of pain (using 11-point verbal analogue) were

used to collect data. Results reflected a positive change in B P and pulse, reduction in

pain, anxiety and depression and the sense of wellbeing after both the humidified water

treatment and the lavender treatment. Following the control session there was also slight

improvement in vital signs, depression and sense of wellbeing, but not in pain or anxiety

levels17.

A randomised study in USA looked at the effects of lavender essential oil

combined with massage on 100 patients in a critical care unit in which 30 patients were

randomly selected into 3 groups. One group received massage plus lavender oil, one

received massage alone and the third rested without any massage or lavender. Data was

obtained using questionnaire to document pain and wakefulness and by measuring heart

rate, blood pressure, and respiratory rate. The study provided no statistics or analysis. The
 10

results showed a 50% reduction in pain with lavender oil, 41% reduction in massage only

and only 16% reduction in control group18.

The effect of aromatherapy on pain, depression and feelings of satisfaction in life

of arthritis patients was investigated using a quasi-experimental design with a non-

equivalent control group, pre and post test among 40 patients enrolled in the Rheumatics

Centre, South Korea. The essential oils used were lavender, marjoram, eucalyptus,

rosemary and pepper mint. The data were collected in the form of pain score and

depression score which were analysed using a 2-test, Fischers exact test, t-test and paired

t-test. In the study aromatherapy significantly decreased both pain score and depression

score of experimental group compared with the control group19.

A study to determine if aromatherapy acupressure, compared to acupressure

alone, was effective in reducing hemiplegic shoulder pain and improving motor power

was done in 30 stroke patients at College of Oriental Medicines, South Korea. It was a

randomised control trial in which subjects were randomly assigned to experimental group

(n=15) or control group (n=15). Each acupressure session lasted 20 minutes and was

performed twice-daily for two weeks. Shoulder pain and motor power were assessed and

analysed using coefficient of correlation. The pain scores were markedly reduced in both

groups at post treatment compared to pre treatment, the pain scores differed significantly

between the two groups at post treatment and the motor power significantly improved at

post treatment compared to pre treatment in both groups20.

The efficacy of acupressure using aromatic lavender essential oil for pain relief

and enhancing physical functional activities among adults with sub-acute non-specific

neck pain done at Telehealth Clinic and The Community Centre, Hong Kong used an
 11

experimental study design. In this study a course of 8-session manual acupressure with

lavender oil over a 3-week period was used. Data were assessed on neck pain intensity

(by VAS), stiffness level, stress level, neck lateral flexion, forward flexion and extension

in centimetres, and interference with daily activities. The baseline visual analogue scores

for the intervention and the control groups were 5.12 and 4.91 out of 10, respectively21.

Treatment with lavender aromatherapy in the post anaesthesia care unit in the

reduction of opioid requirements of obese patients undergoing laparoscopic adjustable

gastric banding (LAGB) was determined at New York University Medical Centre, USA.

The study design was a prospective randomized placebo control which was carried out on

54 patients undergoing LAGB in which the patients in study group (n=26) were treated

with lavender oil, while the control group (n=27) received non-scented baby oil.

Numerical rating scores (0-10) were used to measure the pain level at 5, 30 and 60

minutes. Sedation was evaluated using the Observer Assessment of Alertness or Sedation

scales (0-5). Data were analysed using Chi-square, unpaired Students t-test or Fishers

exact tests. The results showed that significantly more patients in the control group

required analgesics for post operative pain (82%) than patients in the experimental group

(46%) (p=0.007). Moreover, the lavender patients required significantly less morphine

post operatively than placebo patients: 2.38 mg vs. 4.26 mg, respectively22.

6.3. Problem Statement

A study to determine the effectiveness of aromatherapy on pain among post-

operative patients in orthopaedic ward in a selected hospital, Bangalore.

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6.4. Objectives of the Study

To assess the pain among post-operative patients

To compare pain in both experimental and control group after the intervention

To determine the association of pain with selected baseline variables

6.5. Operational Definitions

Pain:

In this study, pain refers to an unpleasant sensory and emotional

experience associated with surgery as expressed by the patient, which will be

measured by the investigator, using numeric intensity pain scale (NIPS) and by

recording changes in physiological parameters (Blood Pressure, Pulse Rate &

Respiratory Rate).

Aromatherapy:

In this study, it refers to the treatment using dry inhalation of the fragrance

of lavender angustifolia essential oil, for pain relief among post-operative

patients.

Effectiveness:

In this study, it refers to the extent to which aromatherapy results in

reduction in pain levels compared to the pain expressed before aromatherapy

which is measured on numeric intensity pain scale.

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Post-operative Patients:

In this study, it refers to clients who have undergone major orthopaedic

surgery (fracture of long bones, pelvis and vertebrae) admitted in orthopaedic

ward in SJMCH, Bangalore.

Baseline Variables:

In this study, it refers to the age, gender, diagnosis, duration of

hospitalisation, surgical procedure, type of anaesthesia and analgesic use in the

clients.

6.6. Assumption

Pain is a complex, subjective experience for every individual

Aromatherapy rejuvenates the senses and thereby reduces pain sensation

6.7. Delimitation

The study will be generalised only to clients who have undergone major

orthopaedic surgery in SJMCH, Bangalore.

6.8. Projected Outcome

The results of the study will help to identify the effectiveness of aromatherapy on

post-operative pain. This will provide as an evidence for use of aromatherapy as a

complementary method of post-operative pain management, thereby reducing the need

for excessive use of post-operative analgesics among orthopaedic patients.

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6.9. Hypothesis

There will be an association between pain and selected baseline variables at 0.05

level of significance.

There will be a significant change in perception of pain following aromatherapy at

0.05 level of significance.

7. MATERIAL AND METHOD

7.1. Source of Data

7.1.1. Research Design:

An experimental design using two groups will be used for the study.

7.1.2. Setting:

The study will be conducted in the orthopaedic ward of SJMCH which is a 1200

bedded tertiary care teaching institute. The number of beds in Orthopaedic ward is 58,

where on an average of 6-8 patients are undergoing major orthopaedic surgery in a

week. These patients are prescribed post-operative analgesia every 8 th hourly as a

routine.

7.1.3. Population:

In this study, population comprises of male and female post-operative clients

admitted to orthopaedic wards of SJMCH, Bangalore.

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7.2. Method of Data Collection

7.2.1. Sampling Procedure:

Post-operative patients will be selected by convenient sampling technique and

randomly assigned to experimental and control group.

7.2.2. Sampling Size:

Sample size of the study will be 60 orthopaedic post-operative patients, with 30

samples in experimental group and 30 in control group.

7.2.3. Inclusion Criteria for Sampling:

Clients who have undergone major orthopaedic surgery in SJMCH.

Clients who are in post-operative period ranging from 2nd to 4th post-operative

day.

Clients who are willing to participate in the study.

Clients who are alert, conscious and co-operative.

Clients who are able to interpret the Numeric Intensity Pain Scale.

7.2.4. Exclusion Criteria for Sampling:

Clients with post-operative complication

Clients who are on oxygen therapy

Clients with chronic co-morbidity

Clients with history of nasal allergy and Sinusitis

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7.2.5. Instrument Used:

It consists of two sections

Section 1:

Interview schedule for collection of baseline information (Age, Gender,

Educational Status, Duration of Hospitalization, Diagnosis, History of Surgery,

Type of Surgery, Type of Anaesthesia, Post-operative Analgesia and History of

any Allergies)

Section 2:

Numeric Intensity Pain Scale (0-10) to assess pain perception and record of

physiological parameters (Blood Pressure, Pulse Rate & Respiratory Rate) will be

used before, immediately after and 6 hours following aromatherapy.

7.2.6. Data Collection Method

An official written permission will be taken from The Administrator of

Hospital, Research Ethical Committee, Medical Superintendent, Nursing

Superintendent and Head of the Orthopaedic Unit of SJMCH to conduct the study.

Post-operative orthopaedic clients fitting into inclusion criteria will be selected

using convenient sampling and randomly assigned to the experimental and the

control group. The detail procedure of the study and assessment of pain using

NIPS will be individually explained to the patient. Experimental group will be

explained about the use of aromatherapy but nothing will be mentioned about its

effect on pain to avoid psychological effect on pain perception. The baseline

 17

information will be collected using a structured interview schedule prior to the

study. For experimental group, on the 2nd post-operative day pain, blood pressure,

pulse rate & respiratory rate will be assessed at 8 pm after which a cotton ball

with a drop of lavender oil will be placed under the pillow and kept there till 7

am. Pain, blood pressure, pulse rate & respiratory rate will be assessed again at 7

am on removal of the cotton ball and also at 1 pm (6 hours after aromatherapy).

This will be repeated on 3rd and 4th post-operative days. Pain perception, blood

pressure, pulse rate & respiratory rate of control group will also be assessed at the

same time intervals as in experimental group but without applying aromatherapy

(using plain moist cotton). Patients will receive their prescribed dose of oral

analgesics. Use of aromatherapy and assessment of pain, blood pressure, pulse

rate & respiratory rate will be done by the researcher herself.

7.2.7. Data Analysis Plan

Data will be analysed using descriptive methods such as frequency,

percentage, mean and standard deviation; and inferential methods such as t-test,

chi-square test, ANOVA and coefficient of correlation. The findings will be

presented in the form of tables and figures.

7.3. Does the study require any investigation to be conducted on patients or

other humans or animals?

No.
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7.4. Has ethical clearance been obtained from your institution?

Administrative permission and ethical clearance with regard to the study will be

obtained from the research committee of SJMCH, Bangalore prior to the conduction

of study.
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LIST OF REFERENCES

1. Ignatavicius DD, Workman ML. Medical Surgical Nursing-Critical Thinking for

Collaborative Care. 5th edn. Missouri: Elsevier Saunders Publishers; 2006: 63-5,

84.

2. Svensson I, Sjostorm B, Haljamac H. Influence of expectations and actual pain

experiences on satisfaction with post-operative pain management. European

Journal of Pain. 2001 June; 5 (2): 125-35.

3. http://www.indiaprofile.com/ accessed on 15-08-2009

4. Daniels R, Nosek L J, Nicoll L H. Contemporary Medical Surgical Nursing. 1 st

edn. Haryana: Thomson Delmar Learning; 2007: 701.

5. Pain Management Standards. Joint Commission on Accreditation of Health Care

Organisation. American Journal of Nursing. 2001 Nov; 101 (11): 62-3

6. Sylla S H. The Aromatherapy Practitioner Reference Manual. Tampa: 1998.

7. History of Aromatherapy. Available at http://www.aromaweb.com/ accessed on

26-07-2009

8. Ching M. Contemporary Therapy: Aromatherapy in the management of acute

pain. Contemporary Nurse. 1999 Dec; 8 (4): 146-51

9. Antony J V. A study to assess the effectiveness of aromatherapy on physiological

and psychological components of relaxation. Unpublished MSc Nursing Thesis.

St. Johns Medical College Hospital. RGUHS, Bangalore. Dec 2006.

 20

10. Polit D F, Deck C T. Nursing Research-Generating and Assessing Evidence for

Nursing Practice. 8th edn. Philadelphia: Lippincott Williams and Wilkins

Publishers; 2008: 343-4

11. Carr, Eloise C J, Thomas V J. Anticipating and experiencing post-operative pain:

the patients perspective. Journal of Clinical Nursing. 1997 May; 6(3): 191-201

12. Sekar C, Rajashekaran S, Kannan R et al. Pre-emptive analgesia for post-

operative pain relief in lumbosacral spine surgeries: a randomized controlled trial.

The Spine Journal. 2004 May-June; 4 (3): 261-4.

13. Strassels S A, Chen C, Carr D B. Post-operative analgesia: economics, resource

use and patient satisfaction in an urban teaching hospital. Anaesth Analg. 2002;

94: 130-7.

14. Jonas M M. Effectiveness of effleurage back massage on physiological and

psychological components of relaxation. Unpublished MSc Nursing Thesis.

St. Johns Medical College Hospital. RGUHS, Bangalore. October 2006.

15. Usichenko T I, Hermsen M et al. Auricular acupuncture for pain relief after

ambulatory knee arthroscopy-a pilot study. Oxford Journals; 2 (2): 185-9.

16. Rowlings F, Meerabeau L. implementing aromatherapy in nursing and midwifery

practice. Journal of Clinical Nursing. 2003; 12: 405-11.

17. Kowalski S D, Louis M. Use of aromatherapy with hospice patients. American

Journal of Hospice and Palliative Medicine. 2002; 19 (6): 381-6.

18. http://www.altmed.creighton.edu/ accessed on 26-07-2009.

 21

19. Kim M J, Nam E S, Paik S I. Effect of aromatherapy on pain, depression and

satisfaction of arthritis patients. Taehan Kanho Hakhoe Chi. 2005 Feb; 35 (1):186-

94.

20. Shin B C, Lee M S. Effects of aromatherapy acupressure on hemiplegic shoulder

pain: A pilot study. J Altern Complement Med. 2007; 13 (2): 247-51.

21. Yip Y B, Hing-MinTse S. An experimental study on the effectiveness of

acupressure for sub-acute, non-specific neck pain. Journal of Complementary

Therapies in Clinical Practice. 2006 Feb; 12 (1): 18-26.

22. Kim J T, Ren C J, Fielding G A, et al. Aromatherapy on opioid requirement

reduction among LAGB patients. Obes Surg. 2007 Jul; 17 (7): 920-5.
 22

8 SIGNATURE OF CANDIDATE
9 REMARKS OF THE GUIDE

10 NAME AND DESCRIPTION OF

(IN BLOCK LETTERS)

Mrs. REENA MENON
10.1 GUIDE
PROFESSOR,
ST.JOHNS COLLEGE OF NURSING.

10.2 SIGNATURE
10.3 CO-GUIDE (IF ANY) Dr. GOURAV SHARMA,
PROFESSOR,
ORTHOPAEDIC DEPARTMENT,
ST.JOHNS MEDICAL COLLEGE
HOSPITAL.

10.4 SIGNATURE
 23

11 11.1 HEAD OF THE PROF. MADONNA BRITTO,

DEPARTMENT PRINCIPAL,
DEPARTMENT OF MEDICAL-
SURGICAL NURSING,
ST.JOHNS COLLEGE OF NURSING.

11.2 SIGNATURE
12 12.1 REMARKS OF THE

CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE