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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE – 2
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. NAME
OF
CANDIDATE
AND ANGELINE KURIAN
ADDRESS
1ST YEAR M. SC NURSING
ST. JOHN’S COLLEGE OF NURSING
BANGALORE-34
2. NAME OF THE INSTITUTION
ST.JOHN’S COLLEGE OF NURSING
3. COURSE OF SYUDY SUBJECT
M.SC NURSING
CHILD HEALTH NURSING
4. DATE OF ADMISSION TO COURSE
MAY 2ND, 2012
5. Title of the Topic
IMPACT OF ADHERENCE TO A VENTILATOR ASSOCIATED PNEUMONIA
(VAP) BUNDLE ON THE INCIDENCE OF VAP IN PICU.
6. Brief resume of the intended work
6.1 Need for the study
Intensive care units have come to represent the most frequently identifiable source of
nosocomial infection within hospital, with the infection rates and rate of antimicrobial
resistance several fold greater than General hospital settings. Ventilator associated
pneumonia (VAP) is defined as nosocomial pneumonia in ventilated patients that develop
more than 48 hours after initiation of mechanical ventilation(MV). VAP is the second most
common nosocomial infection after urinary tract infection in pediatric intensive care unit
patients accounting for 20% of nosocomial infection in this population. VAP can be of two
types. Early onset VAP which develops within 5 days of mechanical ventilation and late
onset VAP which develops 5 days or more after mechanical ventilation.1
The number of VAP cases per 1000 ventilator days, is the standard measure for surveillance
by the CDC and are outlined in CDC guidelines. The incidence of VAP in PICU is 18.7 per
1000 days of mechanical ventilation. Ventilator associated pneumonia occurs in 9 to 27% of
all intubated patients and 28 to 40% of brain injury in ventilated patients develops due to
this condition.Ventilator Associated - Pneumonia occurs up to 17 times more frequently in
developing countries than elsewhere and has a mortality rate as high as 27%, among all other
infections. The risk of VAP is higher during early course of hospital stay. It is estimated to
be 3% during first 5 days, decreasing to 2% during 5 to 10 days of mechanical ventilation
and to 1% afterwards. Among hospital acquired infections VAP is the leading cause of
death, exceeding the rate of death due to central line infections, severe sepsis, and respiratory
infections in the non-intubated patients. Hospital mortality of ventilated patients who
develop VAP is 46%, in comparison with 32% of ventilated patients who do not develop
VAP. Patients with VAP have longer stays in the ICU and in the hospital than the uninfected
patients, even after adjusting for the underlying severity of their illness.2
VAP has been associated with increased length of ventilator dependence, increased PICU
and hospital stay, increased mortality, and increased hospital costs. Patients who developed
VAP had a significantly higher overall mortality rate, increased PICU mortality rate and 56
and 43% increase in the length of PICU and hospital stay respectively.3
The primary route of VAP pathogenesis is a combination of two processes; bacterial
colonization of the aero-digestive tract and the subsequent aspiration in to the lower airway.
Early onset pneumonia is usually caused by Staphylococcus aureus, Haemophilus influenza
and Streptococcus pneumonia, and late onset pneumonia is caused by Methicillin Resistant
Staphylococcus Aureus, Pseudomonas aeruginosa, and Acinetobacter or enterobacter.
Traditional signs and symptoms of VAP are chest X-ray showing new or progressive diffuse
infiltrate which is not attributable to any other causes, onset of purulent sputum, fever greater
than 38.5
0
C, leukocytosis, and positive sputum or blood cultures. The single largest risk
factor for VAP is the presence of endotracheal tube. Patient related risk factors include
underlying chronic illness, immunosuppression, depressed consciousness, thoracic or
abdominal surgery, previous antibiotic therapy and previous infection. Devise, treatment and
personnel related risk factors include nasogastric tube placement, bolus enteral feeding,
gastric over distension, stress ulcer treatment, supine patient position, nasal intubation route,
instillation of normal saline, understaffing, non-conformance to hand washing protocol,
indiscriminate use of antibiotics and lack of training in VAP prevention. 4
Risk factors for development of VAP can be classified in to modifiable and non modifiable
conditions. Risk factors can be patient related or treatment related. Modifiable risk factors
are obvious targets for improved management and prophylaxis in the comprehensive
Guidelines for preventing Health care associated pneumonia, published by centre for disease
control. Effective strategies include strict infection control, alcohol based hand disinfection,
monitoring and early removal of invasive devices and programs to reduce or alter antibiotic
prescribing practices.6
Interventions to prevent VAP begin at the time of intubation and should be continued until
extubation. Nurses need to understand the pathophysiology of VAP, risk factors and
strategies that may prevent VAP. Use of study education modules on nursing care of patients
at risk of VAP and use of ventilator pathways or protocols with pre-printed order sets and
monitoring tools can lead to improved outcome for patients.5
A pre test post test study was conducted to assess effectiveness of a multidimensional
approach to reduce ventilator associated pneumonia in a paediatric intensive care units, of 5
developing countries (Colombia, Salvador, India, Philippines and Turkey). During study
period VAP rate was 11.7 per 1000 ventilator days and 8.1 per 1000 ventilator days during
intervention period, demonstrating 31% reduction in VAP rates.5
A cross sectional observational study was conducted to determine frequency of ventilator
associated pneumonia and to identify the associated factors, causative organisms and
outcome of VAP in children admitted to ICU of Children’s hospital and Institute of Child
Health, Lahore, for 15 months. Out of 93 patients receiving ventilator support during study
period 16 developed VAP (17%). Factors significantly associated with were age less than
one year, unplanned emergency intubation and use of continuous intravenous sedation.
Overall mortality was 23% among ventilated cohort. Average length of stay in ICU among
all ventilated cases were 8.77 days and for the children who developed VAP mean duration
of stay was 13.7 days compared to 7.7 days of those who did not develop VAP.14
St. John’s Medical College Hospital (SJMCH) is a tertiary care centre with bed strength of
1200. Average of 80 to 90 children is admitted per month .Out of which 25 to 30 patients
need ventilator support. Incidence of VAP in PICU is 16%, which means out of 25 ventilated
patients 4 develop VAP. VAP can develop easily in ventilated children, leading to increased
hospital stay, high cost and higher mortality rate. At the same time VAP can be prevented
with implementation of a practice guideline with principles of prevention of iatrogenic
spread of infection (hand hygiene, universal precaution and isolation technique), prevention
of aspiration (head end elevation 30-45 degree and monitoring gastric residual volume ),
oral hygiene(chlorhexidine oral care 6 hourly), avoiding contamination of respiratory
equipment (change ventilator circuit when contaminated, empty respiratory circuit
condensate 6 hourly and disinfect nebulizer unit between each use and using proper suction
technique(do suction only when indicated, thorough suctioning of oropharynx, following
asceptic technique for open tracheal suctioning, avoid instillation of normal saline or sterile
water during tracheal suctioning, use clean glove during closed suctioning and changing
inline suction catheter according to manufacturer’s recommendations or when it is soiled).
Therefore researcher felt a strong need to assess the practice regarding prevention of VAP in
PICU setting. This is planned in order to implement a
ventilator associated pneumonia
bundle , which will provide staff nurses with a base of scientific knowledge and thereby to
reduce the VAP incidences in PIU
6.2 Review of Literature
Review of literature provides base for future investigations, gives an insight in to the
problem, intensifies need for data collection and relates finding of study to another which
would facilitate to establish a comprehensive body of scientific knowledge. Literature is
grouped under 3 headings :
1. Studies related to ventilator associated pneumonia.
2. Studies related to effectiveness of guidelines to prevent ventilator associated
pneumonia.
3. Studies related to health care providers knowledge on ventilator associated
pneumonia.
1. Studies related to ventilator associated pneumonia
A prospective study was performed to detect the various etiological factors of VAP and the
prevalence of multidrug resistant pathogens (MDR), over a period of 15 months, in
Jawaharlal Institute of Postgraduate Medical Education and Research in Pondicherry, India.
Enterobacteriaceae,
Hemophilus
influenza,
Staphylococcus
aureus
Streptococcus
pnumoniae, Candida were more common in early onset VAP, while fermenters were
significantly associated with late onset VAP (p value 0.0267, chi-square value 4.9). This
study found that VAP is increasingly associated with MDR pathogens and appropriate broad
spectrum antibiotics should be used to treat them.8
A prospective observational study was conducted in NICU of CSM Medical
University, Lucknow (UP) India to assess aetiology and risk factors of VAP in neonates over
a period of one year. Neonates admitted to NICU who required mechanical ventilation for
more than 48 hours were enrolled in to the study. The study group comprised of 98 neonates
out of which, 30 neonates developed VAP (30.6%). VAP rates were 37.2 per 1000 days of
mechanical ventilation. Most common bacterial organisms isolated from endotracheal
aspirate of VAP patients were Klebsiella spp(32.8%) , E coli (23.2%), and Acinobacter
(17.8%). Very low birth weight, prematurity, duration of mechanical ventilation, number of
reintubations, and length of ICU stay were significantly associated with VAP in bivariate
analysis. Multiple regression analysis revealed that duration of mechanical ventilation (OR
1.10, 95% CI 1.02, 1.21; p=0.021) and very low birth weight (OR 3.88, 95% CI 1.05, 14.34;
p= 0.042) were two statistically significant risk factors in predicting VAP.1
A prospective observational study was conducted for one year in the PICU of Postgraduate
Institute of Medical Education and Research, Chandigarh, India, to determine the incidence,
aetiology and risk factors for nosocomial pneumonia (NP). Patients who needed ventilator
support, were included and diagnosis of nosocomial pneumonia was made with regard to
CDC guideline. Out of total sample 30.5% developed nosocomial pneumonia. Re intubation
prolonged duration of ventilation. Mechanical ventilation was the significant risk factor for
development of NP. On multiple regression analysis re-intubation was the single risk factor
for NP. Overall mortality rate was 21%, and 7% of these deaths were due to Nosocomial
Pneumonia.12
2. Studies related to effectiveness of ventilator associated pneumonia bundle
A double blind randomized placebo controlled trial was conducted in Pediatric intensive care
unit of All India Institute of Medical Sciences, New Delhi, to study the efficacy of oral
mucosal decontamination with chlorhexidine gel for the prevention of ventilator associated
pneumonia in children between 3 months and 15 yrs. Either 1% chlorhexidine or placebo gel
was applied on the buccal mucosa at 8-hr intervals for the entire duration of ventilation,
subject to a maximum of 21 days. Patients were followed up for the development of
ventilator-associated pneumonia, diagnosed using the Centers for Disease Control and
Prevention criteria. 41 children received 1% chlorhexidine, whereas 45 received placebo
application. Incidence of ventilator-associated pneumonia was 39.6/1,000 ventilator days
with 1% chlorhexidine and 38.1/1,000 ventilator days with placebo (relative risk 1.03,
confidence interval 0.44-2.42, p = .46). The duration of intensive care unit stay and hospital
stay was a mean of 8.4 ± 5.8 vs. 9.6 ± 11.days (p = .58) and 16.1 ± 10.2 days vs. 15.1 ± 14.3
days (p = .19) with chlorhexidine and placebo, respectively. The mortality rates were similar
in the two groups (p = .81). All but two isolates causing ventilator-associated pneumonia
were gram-negative, with Acinetobacter species being the most common (14 of 26). No side
effects of the applied gel were seen in either group.7
A survey was conducted on current practices of intensivists practicing in Indian subcontinent
to assess how VAP is managed. Three hundred, 10 point questionnaires were distributed and
majority (96.8%) reported using VAP bundles with head of bed elevation (98.4%),
Chlorhexidine mouth care (83.3%), stress ulcer prophylaxis (96.8%), heat and moisture
exchangers (92.9%), early weaning(94.4%) and hand washing (97.6%) as part of their
bundle. Majority reported, that they are using (39.7%) proton pump inhibitors for stress ulcer
prophylaxis. 84.1% believed that VAP contributed to increased mortality.9
Another before and after structured study was conducted in an 18 bedded mixed medical
surgical ICU of a hospital in Edinburg, United States of America to determine the effect of
implementing VAP bundle of care. Main results showed that, compliance with head of bed
elevation and chlorhexidine gel were 95-100%; compliance with wake and wean element
was 70% and overall bundle compliance was 70%.Compared to pre intervention period,
there was a significant reduction in VAP in post intervention period (32 cases per 1000
ventilator days to 12; p< 0.001). Statistical process control charts showed the decrease was
more marked after VAP bundle implementation. Patient cohorts staying > 6 and >14 days
had greater reduction in VAP acquisition and also had reduced antibiotic use (reduced by 1
and 3 days; p= 0.008/ 0.001).10
A pre- test post- test design study was conducted over a period of 05 months, in the
University District Hospital in Atlanta, United States of America, to assess compliance to
ventilator bundle strategies. Compliance was evaluated daily in random shifts after
conducting lectures, bed pamphlets and card reminders. Pre educational compliance was 6%.
Individual component compliance was head of bed elevation 14%, withdrawal of sedation
67%, peptic ulcer prophylaxis 93%, deep venous thrombosis prophylaxis 87%. Post
educational compliance was 59% with individual compliance of 74%, 72%, 95%, and 92%
respectively. A statistically significant increase in compliance was observed in ventilator
bundle compliance and HOB elevation (p< 0.01).2
Another prospective study was conducted to assess impact of adherence to a ventilator
associated pneumonia bundle on the incidence of VAP in surgical intensive care unit of
Boston Medical Centre in Boston over a 38 month period. A daily checklist was considered
compliant if all the items were performed for all patients. Prior to initiation of bundle VAP
was seen at a rate of 10.2 cases per 1000 ventilator days. Compliance with bundle increased
over the study period from 53% and 63% to 91% and 81% in each respective SICU. The rate
of VAP decreased to 3.4 cases per 1000 ventilator days. 11
3. Studies related to health care providers knowledge on ventilator associated
pneumonia
A single group pre test post test study was conducted to assess nurse’s knowledge on
evidence based guideline for prevention of ventilator associated pneumonia in critical care
area, in a private tertiary care hospital in Karachi, Pakistan. Knowledge of nurses was
assessed before, immediately after and after 4 weeks of intervention. The demographic data
sheet was used to collect relevant information about participants. Knowledge scores of
participants increased significantly, immediately after educational intervention.15
A descriptive study was conducted to detect knowledge of nurses working in ICU with
respect to evidence based guideline for prevention of ventilator associated pneumonia in
Johannesburg, South Africa. The nurses performed poorly in the test, with only 21.9% of
participants obtaining a mark at or above competency level. 16
6.3 Statement of the problem
A study to assess the impact of adherence to ventilator associated pneumonia (VAP) bundle
on the incidence of ventilator associated pneumonia (VAP) in PICU of a selected hospital
in Bangalore.
6.4 Objectives of the study
1. To assess the practice before and after implementation of ventilator associated pneumonia
bundle.
2. To compare the incidence of ventilator associated pneumonia before and after
implementation of VAP bundle.
3. To find association between incidence of ventilator associated pneumonia and patient’s
baseline variables.
6.5 Operational definition
1. Impact
Dictionary meaning of impact is a noticeable effect or influence. (Oxford dictionary 2011)
In this study impact refers to extent to which adherence to VAP bundle in practice have
occurred and decrease in the incidence of VAP after implementation of VAP bundle,
assessed and scored by observation and record analysis.
2. Adherence
Dictionary meaning of adherence is to stick firmly or follow.
In this study meaning of adherence
is following all aspects of ventilator associated
pneumonia bundle assessed and scored by observation and record analysis.
3. Ventilator associated pneumonia (VAP) bundle.
ventilator associated pneumonia (VAP) bundle is grouping of best practices supported by
evidence strategies, with respect to ventilator associated pneumonia prevention (IHI 2011)
In this study meaning of ventilator associated pneumonia (VAP) bundle is comprehensive
recommendations for prevention of ventilator associated pneumonia which include
prevention of
iatrogenic spread of infection (hand hygiene, universal precaution),
prevention of aspiration (head end elevation 30-45 degree and monitoring gastric residual
volume), oral hygiene(chlorhexidine oral care 6 hourly), avoiding contamination of
respiratory equipment (change ventilator circuit when contaminated, empty respiratory
circuit condensate 6 hourly), using proper suction technique (do suction only when indicated,
thorough suctioning of oropharynx, following
asceptic technique for open tracheal
suctioning, avoid instillation of normal saline or sterile water during tracheal suctioning and
use clean glove during closed suctioning ) and peptic ulcer disease prophylaxis
(administration of Sucralfate)
4. Incidences
Dictionary meaning of incidence is rate or frequency of occurrence of something.
In this study incidence meaning is number of VAP cases per 1000 ventilator days.
Incidence of VAP =Patients with VAP/Patients on ventilator*1000.
5. Ventilator associated pneumonia
Pneumonia in patients who have been on mechanical ventilation for greater than 48 hours
(CDC guideline 2012)
In this study ventilator associated pneumonia is a nosocomial lower respiratory tract
infection occurring in mechanically ventilated patients 48 hours or more after initiation of
ventilator support as diagnosed by physician.
6. Pediatric intensive care unit
A special area in the hospital where critically ill pediatric patients who need close
observation and frequent ministrations can be cared for by qualified, trained staff working
under the best possible conditions.
7.Baseline variable
In this study patient’s baseline variables are age, sex, diagnosis, number of days of
mechanical ventilation and number of intubations.
6.6 Assumption
1. There will be some practice measures followed in PICU regarding ventilator associated
pneumonia prevention.
2. VAP bundle may reduce the incidence of ventilator associated pneumonia in PICU.11
6.7 Delimitations
This study is limited to, mechanically ventilated pediatric patients in PICU of St. John’s
Medical College Hospital, Bangalore.
6.8 Projected outcome
The result of the study will help to identify the effectiveness of VAP bundle in reducing
ventilator associated pneumonia and this will provide guideline for nurses in preventing
VAP in PICU.
6.9 Hypothesis
H1. There will be a significant difference in the mean practice score before and after
implementation of VAP prevention guideline at 0.05 level of significance.
H2. There will be significant association between incidence of VAP and baseline variables of
patients (age, sex, diagnosis, number of days on mechanical ventilation and number of
intubations)
7. Material and method
7.1 Source of data
Interventions carried out for mechanically ventilated pediatric patients.
7.1.1 Research design
Research design selected for this study is quasi experimental design, in order to assess
practice before and after implementation of ventilator associated pneumonia bundle.
7.1.2 Study setting
This study is planned to conduct in St. John’s Medical College hospital, Bangalore. It is
1200 bedded, tertiary care hospital, with pediatric services. The study setting is Pediatric
Intensive Care Unit. The PICU consists of 12 beds and there are 18 staff nurses and 7
doctors. On an average there are 25 to 30 patients who require ventilator support per month.
7.1.3 Population
Population in this study comprise of all patients who are on ventilator support at the time of
study, in SJMCH, Bangalore.
7.2 Method of data collection
7.2.1 Sampling procedure
Sampling procedure refers to process of selecting a portion of population to select the entire
population. Purposive sampling is the sampling technique planned for the study.
7.2.2 Sampling size
23 pediatric patients on ventilator support who meet inclusion and exclusion criteria in PICU
of SJMCH should be assessed before and after implementation of VAP bundle to observe the
difference in compliance with 20% precision and 95% confidence interval.
7.2.3 Inclusion criteria for sampling
Patients who are on ventilator support at the time of study.
7.2.4 Exclusion criteria for sampling
1. Patients who require ventilator support for less than 48 hours.
2 .Patients on ventilator with cervical injury
3. Known hypersensitivity to chlorhexidine.
7.2.5 Instrument used
1. Baseline performa
2. Record analysis to assess clinical pulmonary infection score.
3. Observations performed to assess the practice in PICU regarding prevention of ventilator
associated pneumonia.
7.2.6 Data collection method
After getting a formal administrative permission samples will be identified as per inclusion
and exclusion criteria using purposive sampling technique. Practice will be assessed using
observation checklist and record analysis for 5 weeks.23 patients will be assessed and 2
observations each lasting for 2 hours will be made on each patient before implementation of
bundle. Incidence of VAP will be assessed as per physician’s diagnosis. VAP bundle will be
implemented through structured teaching and will be displayed in the PICU. A time period
of 1 week is planned before assessing post implementation practice. The post
implementation practice will be assessed using observation checklist and record analysis for
5 weeks. 23 patients will be assessed and 2 observations will be made on each patient. The
incidence of VAP will be assessed as per doctor’s diagnosis.
7.2.7 Data analysis plan
Organize data in a master sheet.
Data will be analyzed using descriptive and inferential statistics.
Frequency and percentages to show the distribution of subjects according to baseline
variables.
Paired t test for comparing pre and post practice score.
Chi square for association.
7.3 Does the study require any investigation or intervention to be conducted on
patients or other humans or animals? If so please describe briefly.
No.
7.4. Has ethical clearance been obtained from your institution in case of 7.3?
Not applicable
List of references
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Neonatal Intensive Care Unit characteristics, risk factors and outcome. Internet journal of
medical update 2010 Jan (cited on 2012Aug 2) ; 5(1) : Available from : URL:
http://www.akspublication.com/ijmu
2. Jimenez L,
Pastrana EA, Rodriguez GV, Vega GR, Rolston JD. Ventilator bundle
compliance report from a neurosurgical intensive care unit. Critical care and shock 2009;
12:109-116
3. Morrow BM, Argent AC, Jeena PM, Green RJ. Guideline for the diagnosis prevention and
treatment of pediatric ventilator associated pneumonia. S Afr Med 2009; 99: 1-13
4. Hoosre DTV. Ventilator associated pneumonia best practice strategies for care givers.
Protection for life Kimberly Cark Health Care; 2002: 1-19
5. Augustyn B. Ventilator associated pneumonia risk factors and prevention. Critical care
nurse 2007; 27 (4): 32-40
6. Michael S, Niederman MD, Donald E, Craven MD. Guideline for the management of
adults with hospital acquired ventilator associated and health care associated pneumonia.
American journal of respiratory critical care medicine 2005; 171: 388-416
7. Sebastian M, Lodha R, Kapil A, Kabra SK. Oral mucosal decontamination with
Chlorhexidine for the prevention of ventilator associated pneumonia in children a
randomized control. Pediatric critical care medicine 2012
8. Joseph NM, Sistla S, Dutta TK, Badhe AS, Rashitha D, Parija SC. Ventilator associated
pneumonia in a tertiary care hospital in India role of multidrug resistant pathogens J Infect
Dev Ctries 2010; 4(4):218-225
9. Juneja D, Singh O, Javeri Y, Arora V, Dang R, Kaushal A. Prevention and management
of ventilator associated pneumonia. A survey on current practices by intensivists practicing
in Indian subcontinent. Indian journal of anaesthesia 2011 Mar-Apr; 55(2): 122-128
10. Morris AC, Hay AW, Swann DG, Everinham K,MucCulloch C, McNutty J et al.
Reducing ventilator associated pneumonia in intensive care impact of implementing a care
bundle . Crit care med 2011; 3a (10): 1-7
11. Bird D, Zambuto A, Donnel CO, Silva J, Korn C, Burke R, Burke P et al. Adherance to
ventilator associated pneumonia bundle and incidence of ventilator associated pneumonia in
the surgical intensive care unit. Arch Surg 2010; 145(5): 465- 470
12. Patra PK, Jayashree M, Singhi S, Ray P, Saxena AK. Nosocomial pneumonia in pediatric
intensive care unit. Indian pediatrics 2007 July ; (44): 511-518
13. Victor D, Rosenthal MD, Moreno CA, Gomes WV, Singh S, Ramachandran B.
Effectiveness of multi dimensional approach to reduce ventilator associated pneumonia in
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Aug 2). Available from: URL: http: // www.ajicjournal.org
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Pakistan 2012; 22(3): 155-158.
15. Meherali S M, Parpio Y, Ali T S, Javed F. Nurses knowledge on evidence based
guideline for prevention of ventilation associated pneumonia in critical care areas: a pre test
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16. Gomes V P R. Knowledge of intensive care nurses on evidence based guideline for
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8.
SIGNATURE OF CANDIDATE
9.
REMARKS OF GUIDE
10.
NAME & DESIGNATION OF:
MRS. SHINY MATHEW
10.1: GUIDE
ASST. PROFESSOR
ST.JOHN’S COLLEGE OF NURSING
BANGALORE
10.2: SIGNATURE
DR. LALITHA A. V
10.3: CO- GUIDE
ASST. PROFESSOR
ST.
JOHN’S
MEDICAL
COLLEGE
HOSPITAL
BANGALORE
10.4: SIGNATURE
MRS. SHEEJA P. P
11.
11.1: HEAD OF THE
DEPARTMENT
ASSO PROFESSOR
ST. JOHN’S COLLEGE OF NURSING
BANGALORE
11.2: SIGNATURE
12.
12.1: REMARKS OF THE
CHAIRMAN AND THE
PRINCIPAL
12.2: SIGNATURE