A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON PREVENTION OF

PRESSURE ULCER AMONG FRACTURE PATIENTS IN SELECTED HOSPITAL AT BANGALORE.

M.Sc Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

By

Mrs. PRIYANKA LALAN

M.Sc NURSING 1ST YEAR

2009-2011

Under the Guidance of

HOD, Department of Medical Surgical Nursing

National College of Nursing

Hegganahalli Cross

Vishwaneedam Post

Magadi Road

Bangalore –91

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Diseases can rarely be eliminated through early diagnosis or good treatment, but prevention can eliminate disease”

All around the world people are mobilizing to bring better health conditions and health care —so that they can have a fighting chance to raise families, grow communities, find meaningful work, and contribute to society. But often people take health for granted and do not fully appreciates until it lost the meaning of health is misunderstood and misinterpreted by many people. This is because of lack of complete scientific information and poor instructions. It is subjective and abstract. Health promotion and prevention enables individuals, families and communities to develop their full health potential. Maintaining skin integrity is important. A few client populations are thought to be at greater risk of developing pressure sores because of immobility like Orthopaedic clients with fractures, the elderly with femoral fractures and client in nursing settings home settings. Studies in the latter have shown that the incidence of pressure ulcers increases with length of stay.1

A pressure ulcer is an area of skin that breaks down when the client stays in one position for too long without shifting the weight. This often happens if he uses, a wheel chairs or he is bedridden, even for a short period of time (for example after surgery, an injury). The constant pressure against the skin reduces blood supply to that area and the affected tissue dies. The most common place for pressure ulcers are over bong prominence (bone close to the skin) like the elbow, heals, hips, ankles, shoulders, back and the occiput of the head.2

Pressure sores can develop in unexpected place assess the whole client when determining pressure sore risk. Therefore in this case patients part is very essential one and the nurses responsibility is giving health education to patients and his family members. Research indicates that care giving is associated with biomarkers of chronic stress. Therefore the investigator recognized the significance of giving

a planned teaching programme for patients to get adequate knowledge to prevent pressure ulcer.

Nurses play a major role in prevention of pressure ulcer, as she is the one who early recognise the signs of pressure ulcer during patients stay in hospitals with immobility or fracture. She should observe for the adequate integrity of the skin and should encourage the patient to take all measurements to prevent ulcer with planned teaching programme.3

6.1 NEED FOR THE STUDY

Pressure sores are common conditions among patients hospitalized in acute- and chronic-care facilities. Prevention of pressure ulcer is always better than treating the complication associated with it, with higher expenses. Pressure ulcer occurs almost exclusively in people with limited mobility, so it is a challenge to prevent the occurrence of pressure ulcer. When considering pressure ulcer prevalence defined as number of clients with at least one pressure ulcer who exist in a client population at a given point in time (WOCN, 2004).More that 1 million individuals develop pressure ulcer each year (WOCN, 2003).Where there is a risk for pressure ulcer development preventive interventions such as skin care practices, elimination of shear and positioning are high priorities.4

The reported incidence of pressure ulcer in aute care facilities ranges from 2.7% to 29.5% and approximately 5-8% annually and 25-85% of these patients develop a pressure sore at some time. The prevalence in acute care setting ranges from 3.5% to 29.5% and 2.4% to 23% in nursing homes and about 20% at home in people older than 65. Studies have suggested that, at any given time, 3-10% of hospitalized persons have pressure sores and 2.7% develop new pressure sores.3 Among a selected population, the incidence rate for the development of a new pressure sore has been demonstrated to be much higher, with a range of 7.7-26.9%. Once again, the treatment of pressure sores in this patient population represents a financial challenge, with an average cost per admission of a patient with a pressure sore of $78,000 at one hospital.5

A study was conducted on pressure ulcer prevalence rates from 2002 to 2008 in German long-term care facilities. The study group comprised of 18,706 residents in 218 long-term care facilities (response rate 77.5%). Application of Chi-square tests, chi-square

trend tests and one-way ANOVA to assess differences and trends across the years. The result shows that regarding gender, age, and pressure ulcer risk, the yearly samples were comparable. Pressure ulcer prevalence rates decreased from 12.5% (year 2002) to 5.0% (year 2008) (p<0.001). Prevalence rates, excluding non-blanch able erythema, decreased from 6.6% (year 2002) to 3.5% (year 2008) (p<0.001).6

A study conducted on prevalence of pressure ulcers in hospitalised patients in a university hospital in India. A total of 445 patients hospitalised in medical and surgical wards were examined in a single day for the number, site and grade of pressure ulcers. Haemoglobin, serum albumin and blood sugar levels of patients with pressure ulcers were recorded. The result was the prevalence of pressure ulcers was high (4.94%). Anaemia, malnutrition and diabetes were important risk factors, while morbidity due to pressure ulcers in long-stay wards, such as neurology, was exceptionally high (40.9%).7

There was a study to determine the quality of protocols for pressure ulcer prevention in home care in the Netherlands with current pressure ulcer prevention protocols from 24 home-care agencies were evaluated. A checklist developed and validated by two pressure ulcer prevention experts was used to assess the quality of the protocols, and weighted and unweighted quality scores were computed and analysed using descriptive statistics. The results was 24 pressure ulcer prevention protocols had a mean weighted quality score of 63.38 points out of a maximum of 100 (sd 5). The importance of observing the skin at the pressure points at least once a day was emphasized in 75% of the protocols. Only 42% correctly warned against the use of materials that were 'less effective or that could potentially cause harm'.8

A study was done to implement and evaluate a heel pressure ulcer prevention program (HPUPP) for orthopaedic patients in Canada. Program development of HPUPP involved input from administrators, staff and adult patients on an orthopaedic service in an academic tertiary care facility, located in a small urban centre in Canada. Prospective evaluation was conducted. After the program was implemented, the incidence of heel pressure ulcers was 0%, which was a significant reduction compared with pre-implementation levels [13.8% (95% confidence interval 8-18%)].9

Pressure sores can develop in unexpected place assess the whole client when determining pressure sore risk. As a nurse we have a greater role in preventing pressure ulcer when the patient is hospitalized by giving positioning, checking their nutritional, maintaining good skin care and cleaning therefore in this case patients part is very essential one and the nurses responsibility is giving health

education to patients and his family members. Research indicates that care giving is associated with biomarkers of chronic stress. Therefore the investigator recognized the significance of giving a planned teaching programme for patients to get adequate knowledge on prevention of pressure ulcer.10

6.2 REVIEW OF LITERATURE

A literature review is designed to identify related research, to set the current research project within a conceptual and theoretical context. So that we can find out that just about any worthwhile idea you will have has been thought of before, at least to some degree. A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.11

The review of literature which support the study are given below:

A study was conducted “To estimate the frequency of use of pressure-redistributing support surfaces (PRSS) among hip fracture patients and to determine whether higher pressure ulcer risk is associated with greater PRSS use”. Patients (n = 658) aged >or=65 years who had surgery for hip fracture were examined by research nurses at baseline and on alternating days for 21 days obtained .The result was a PRSS was observed at 36.4% of the 5,940 study visits. The odds of PRSS use were lower in the rehabilitation setting (adjusted odds ratio [OR] 0.4, 95% confidence interval [CI] 0.3-0.6), in the nursing home (adjusted OR 0.2, 95% CI 0.1-0.3), and during readmission to the acute setting (adjusted OR 0.6, 95% CI 0.4-0.9) than in the initial acute setting.12

A study had done “To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the post fracture period”. Prospective cohort study was used. The result said that in 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR) =2.2, 95% confidence interval

(CI) =1.3-3.7) and during re-admission to the acute hospital (RR=2.2, 95% CI=1.1-4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8-2.3) and 1.3 (95% CI=0.8-2.1), respectively.13

A study was conducted on “Malnutrition is a risk factor for development of pressure ulcers (PU)”. Hip-fracture patients (n=103) were included in this double-blind, randomised, placebo-controlled trial. They received 400 ml daily of a supplement enriched with protein, arginine, zinc and antioxidants (n=51) or a non-caloric, water-based placebo supplement (n=52). The result was the incidence of PU was not different between supplement (55%) and placebo (59%), but incidence of PU stage II showed a 9% difference (difference: 0.091; 95% CI: 0.07-0.25) between supplement (18%) and placebo (28%). Of patients developing PU 57% developed it by the second day. Time of onset (days) showed a trend (P=0.090) towards later onset of PU with supplement (3.6+/-0.9) than placebo (1.6+/-0.9).14

A study was conducted on “Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors”. Incidence of between 8.8% and 55% have been reported. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as sub scores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Co morbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006).15

A study done ,were to (i) investigate the incidence of pressure ulcers in 1997 and 1999 among patients with hip fracture, (ii) study changes of nursing and treatment routines during the same period and (iii) to identify predictors of pressure ulcer development. Comparative study was based partly on data collected in two prospective, randomized, controlled studies conducted in 1997 and 1999. Patient with hip fracture, > or = 65 years, admitted without pressure ulcers. Forty-five patents were included in 1997 and 101 in 1999. AS per the result, there was a significant reduction of the overall incidence of pressure ulcers from 55% in 1997 to 29% in 1999. The nursing notes had become significantly more informative.16

A study done on “Impact of prevention structures and processes on pressure ulcer prevalence in nursing homes and acute-care hospitals.”A total of 7377 residents in 60 nursing homes and 28,102 patients in 82 acute-care hospitals in Germany participated in annual point prevalence surveys. The result was samples within the arranged groups showed no clinically relevant demographical differences. Nosocomial prevalence rates in hospitals dropped from 26.3% in the first year to 11.3% in the last year (nursing homes from 13.7% to 6.4%). The use of pressure ulcer-related structures remarkably increased during each repetition to more than 90%.17

A study conducted on pressure ulcer prevalence and incidence of acute care hospital.116 acute care facilities from 34 states participated and the sample of 17,560 patients in hospital –based medical-surgical or intensive care unit. The average length of stay for the participating facilities was 5 days .The result was pressure ulcer in 7% of the subject (n-383)90% were stage I or II pressure ulcer and 73% occurred in patients older than 65yrs.The most sites based on both prevalence and incidence measurements were sacrum and coccyx at 26% and 31% respectively.18

A study done on “prevalence and incidence studies of pressure ulcer in long term care facilities in Canada”, with 95 resident and other with 92 residents were selected for study. Data were collected on demography, medication information and possible contributing factors. The result was pressure of pressure ulcer in the 2 long term facilities was 36.8% and 53.2% respectively. The incidence of pressure ulcer on the long term care facilities was 11.7% and 11.6% respectively. The pressure ulcer prevalence is higher than published figure for the long term care setting .The pressure ulcer incidence of less than 2% in each facility suggests an equal and acceptable level of nursing care in both facilities.19

A study conducted on “perception of pressure ulcer among young men with spinal injury” .About 1000 younger people each year suffer a traumatic spinal cord injuries that leaves them wholly or partly paralysised.The majority of these individuals are males. The results suggest that there men were knowledgeable about pressure management and highly motivated to look after themselves but there were an over reliance on the specialist unit for support.20

An study done to “assess selected factors relation to pressure sores among immobilized patients of St.John Medical College and hospital Bangalore, with view of developing standard protocol for its prevention”. Data was obtained from 50 immobilized patients or

their care givers who were admitted emergency ward ICU .The finding of the study revealed that a proportion of 6.75% patients developed pressure sores during the 40 days of the study. The knowledge and opinion of the immobilized patient who developed pressure sores and who did not developed pressure sores was not significant. The knowledge and opinion of the nursing personnel regarding pressure sores and its prevention were not satisfactory despite the fact that it has been taught to them during their courses of training. Based on the finding of the study, the major implication for the study was that knowledge of nursing personnel in relation to pressure sores need to be refreshed and updated.21

A study done on “reduction of nosocomial pressure ulcer in patients with hip fracture a quality control programme”. The nursing quality improvement unit of Israel’s Hadassah mount Scopus medical centre designed and implemented a quality improvement intervention programme to reduce the incidence of nosocomial pressure ulcer. Assessing that, it was found that 46.7% of nosocomial pressure ulcer develops in patients with hip fracture. First intervent programme included providing each with visco-elastic mattress and a cushion for the elevation of the affected limb. This programme conducted in orthopaedic ward and in recovery room, pressure ulcer relieving practices were introduced following the implement of intervention programme, it is revealed in the incidence of nosocomial pressure ulcer from 12.9% to 9% results of the study reveals the patients with hip fracture are still at very high risk of developing nosocomial pressure ulcer , prevention is feasible.22

A study conducted for “evaluation of an evidenced based programme for pressure sore prevention”. The purpose of the study was to implement and evaluate a standardised workshop for and two levels of nursing staff. A quasi experimental design was used. The convenient sample included registered nurses (n=595) and licensed practioner nurses (n=59) employed in there acute care hospital with a total bed capacity of 1760. The questionnaire was pilot test, before use pre-test post- test with three month duration. Data was analysed using descriptive statistics. The result was general knowledge course for the total groups were significantly higher. The evidence based pressure ulcer education was effective increasingly in registered nurses and licensed practical nurses knowledge.23

A study done on “knowledge of pressure ulcer by under graduate nursing students in Brazil”. Third and fourth year undergraduate baccalaureate students at a public university in a Brazil CN= 38 were asked to provide demographic information, identify

extracurricular activities and complete the pressure ulcer knowledge test. Students correctly answered 67.71 of the pressure ulcer knowledge list items. The result was students who participated in extracurricular activities and used the internet had significant impact on knowledge test score. Generally the students were found to have low pressure ulcer knowledge.24

A study conducted on “effectiveness of Individual Planned Teaching to the care givers on prevention of pressure sore in bed ridden patients admitted to Fr Muller Medical College Hospital, Mangalore”. A quasi experimental approach with one group pre-test and post-test adopted for study a sample of 30 care givers of 30 bedridden patients. They were selected by using convenience sampling technique. The result was most of the caregivers (63%) had no prior experience of staying with the patients in the hospital. Majority (90%) of caregivers had a very good knowledge scores (81-100%) in the post test. The mean difference between post-test and pre-test knowledge scores on prevention of pressure sores which was found to be significantly high (29) = (p<0.05)92.25

6.3 STATEMENT OF PROBLEM

“A study to evaluate the effectiveness of planned teaching programme on prevention of pressure ulcer among fracture patients in selected hospital at Bangalore.”

6.4 OBJECTIVES OF STUDY

To assess the level of knowledge regarding prevention of pressure ulcer among fracture patients in selected hospital at Bangalore

To determine the effectiveness of planned teaching programme regarding prevention of pressure ulcer among fracture patients in selected hospital at Bangalore

To find the association between post test knowledge scores with selected demographic variables i.e. age, sex, education, occupation, type of diet and place of residence.

6.5 HYPOTHESIS

H1: The mean post-test knowledge score will be significantly higher than pre-test knowledge score regarding prevention of pressure ulcer among fracture patients.H2: There will be significant association between knowledge scores with selected demographic variables such as age, sex, education, occupation, type of diet and place of residence.

6.6 OPERATIONAL DEFINITION

Evaluate : The term evaluate refers to assessing the effectiveness of planned teaching programme regarding pressure ulcer pre-test and post-test.

Effectiveness : it refers the extent to which the of planned teaching programme has achieved the desire effect as measured by gain in knowledge score.

Planned teaching programme : it refers to information providing pressure ulcer which includes definition, causes, its sign and symptoms, stages, treatment, prevention, complication and nurse’s responsibility.

Prevention : includes primary and secondary measures adopted to protect patients from developing pressure ulcer.

Pressure ulcer : it is localized area of tissues necrosis caused by unrelieved pressure, tissue layers sliding over other tissue layer, shearing and excessive moisture.

Fracture: it is the disruptions or break in the continuity of structure of bone.

6.6 ASSUMPTIONS

The study assumes that:1. Fracture patients need reinforcement of knowledge and practice regarding prevention of pressure ulcer 2. Planned teaching programme will enhance their knowledge in further.

6.8 DELIMITATIONS

1. Data collection period will be for 4 weeks2. Sample size is 60

6.9 PROJECTED OUTCOME

Planned teaching programme will improve knowledge and they will practice the preventive measures such as positioning, skin care, diet and exercises.

7.0 MATERIALS AND METHODS

7.1 SOURCE OF DATA

Patients who are admitted with fracture.

7.1.1 RESEARCH DESIGN Pre-experimental design. One group pre-test and post-test.

Research approach Evaluative approach will be used for the study.

7.1.2 SETTING OF THE STUDY K.C General Hospital at Malleswaram

7.1.3 POPULATION

Patients who have fracture

7.2 METHODS OF COLLECTION OF DATA

Structured Interview Schedule will be used to assess the knowledge regarding prevention of pressure ulcer among fracture patients in selected hospital at Bangalore.

Interview will be conducted between 9am to 3pm.Data will be collected from 6 patients per day. The duration of 30 minutes will be spend per each subject.

The duration of the study will be 4weeks. In the first 2 weeks pre-test will be conducted and structured teaching programme will be given and then for the next 2weeks post-test will be conducted.

7.2.1 SAMPLING TECHNIQUE Convenient sampling technique will be used for this study.

7.2.2 SAMPLE SIZE The sample size is 60

7.2.3 INCLUSION AND EXCLUSION CRITERIA

INCLUSION CRITERIA:

Who are having fracture. Who are willingly participate in the study Those who known English and Kanada

EXCLUSION CRITERIA:

Patients with complication Patients will skull, humerus fracture. Patients with pressure ulcer.

7.2.4 DATA COLLECTION TOOLQuestionnaire which contains section A and section B

SECTION A: consists of demographic variables like age, sex, education, occupation, type of diet and place of residence.

SECTION B: Questionnaire will be used to assess the knowledge regarding prevention of pressure ulcer using 25 questions.

SCORING PROCEDURE

For correct answer score will be given as 1. For incorrect answer score will be given as 0. * Score 1 will be given for agree * Score 0 will be given for disagree

Based on the score knowledge level will be classified into: 75% to 100% - adequate 50% to 75% - average Below 50% - inadequate

7.2.5 DATA COLLECTION METHODS Prior permission will be obtained by the significant authorities

and from the subject. The investigator will use questionnaire to assess the knowledge regarding prevention of pressure ulcer among fractured patients.

Interview will be conducted between 9am to 3pm.Data will be collected from 8 patients per day. The duration of 30 minutes will be spending with per each subject.

The duration of the study will be 4weeks. In the first 2 weeks pre-test will be conducted and structured teaching programme will be given and then for the next 2weeks post-test will be conducted.

7.2.6 PILOT STUDY PLAN

6 samples will be taken and study will be conducted to find out the feasibility.

7.2.7 DATA ANALYSIS METHOD

The data collected from garments where be grouped and by statistical measures in terms of objectives.

1. Number and %distribution to explain demographic variables and knowledge level.

2. The significance of relationship between the selected demographic variables and knowledge scores will be analyzed by using chi square

7.3 DOES THE STUDY REQUIRE ANY INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS: YES7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION? PERMISSION WILL BE OBTAINED FROM:

YES, ethical clearance will be obtained from the research committee of NATIONAL College of Nursing.

Consent will be taken from the District Medical Officer and study subjects before data collection.

8.0 LIST OF REFERENCES

1. Smeltzer.C.Suzanne,Bare Brenda G “Medical Surgical Nursing”, 10th edition, 2004, Lippincott Williams and Wilkins, pg:175-177.

2. Black.M.Joyce, “Medical Surgical Nursing. Clinical Management For Positive Outcomes”, 7th edition, 2005, Elsevier Missouri, pg:1403.

3. Ingnataricius.D.Donna et.al , “Medical Surgical Nursing. A Nursing Process Approach”, 2nd edition, 1995, W.B.Saunder Company Philadelphia, 1935-1944.

4. Perry. Potter, “Fundamentals of Nursing”, 7th edition, 2009, Elsevier Missouri, pg:1228-1231

5. Bradon J Wilhelmi, “Pressure Ulcers ,Surgical Treatment and Principles”Southern Illinois University School of Medicine, 2010

6. Lahmann NA, Dassen T, Poehler A, Kottner J, “Pressure ulcer prevalence rates from 2002 to 2008 in German long-term care facilities”, Department of Nursing Science, Berlin, Germany, 2010 Apr;22(2):152-6.

7. Chauhan VS, Goel S, Kumar P, Srivastava S, Shukla VK, “The prevalence of pressure ulcers in hospitalised patients in a university hospital in India”, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India,2005Jan;14(1):36-7.

8. Chaves LM, Grypdonck MH, Defloor T, “Protocols for pressure ulcer prevention: are they evidence-based?”, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands, 2010 Mar;66(3):562-72.

9. Campbell KE, Woodbury MG, Houghton PE, “Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population”, London Health Sciences Center, London, Ontario, Canada, 2010 Feb;7(1):28-40.

10. Nettina, Sandra M. (2001). The Lippincott Manual of Nursing Practice, 7th Ed. Philadelphia:Lippincott,WilliamsandWilkins. 

11. Anson, Chris M. and Robert A. Schwegler, “The Longman Handbook for Writers and Readers”, Second edition, New York: Longman, 2000.

12. Baumgarten M et.al, “Use of pressure-redistributing support surfaces among elderly hip fracture patients across the continuum of care: adherence to pressure ulcer prevention guidelines”, Department of Epidemiology and Preventive

Medicine University of Maryland School of Medicine, USA. 2010 Apr;50(2):253-62.

13. Baumgarten M et.al, “Use of pressure ulcers in elderly patients with hip fracture across the continuum of care”, Department of Epidemiology and Preventive Medicine, University of Maryland School ofMedicine, Baltimore, 2009 May;57(5):863-70.

14. Houwing RH et.al “A randomised, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients”, Department of Dermatology, Deventer, The Netherlands. 2003 Aug;22(4):401-5.

15. Lindholm C, et.al “Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors”, Department of Health Sciences, KristianstadUniversity,Sweden,2008Jun;5(2):315-28.

16. Gunningberg L et.al “Reduced incidence of pressure ulcers in patients with hip fractures: a 2-year follow-up of quality indicators”, Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Sweden. 2001 Oct;13(5):399-407.

17. Lahmann NA, Halfens RJ, Dassen T, “Impact of prevention structures and processes on pressure ulcer prevalence in nursing homes and acute-care hospitals”,Department of Nursing Science, Berlin, German. 2010 Feb;16(1):50-6.

18. Whittington “Wound Ostomy Continence Nurs “ K K C L USA, INC Po Box 6595508 San Antonio T X.78265-9508 USA, J:2000 Jul:27(4)2009-15.

19. Davis L M Caseby NG,” Ostomy Wound Management “Roth bart pain Management Clinic, North York, Ontario Canada, , 2001 Nov:47(11) 28-34.

20. Gibson.L. “ Br.J Community Nursing” Florence Nightingale School of Nursing and Midwifery, King’s College London England UK, , 2002 Sep:7(9)451-60.

21.Ms.Sara Ommen “Assess selected factors relation to pressure sores among immobilized patients of St.John Medical College and hospital Bangalore, with view of developing standard protocol for its prevention”, ( Unpublished Masters of nursing Dissertation ,Rajiv Gandhi University of Health Science,Bangalore, Karnataka)2000

22. Piech S, Calderon Margalit R, “Nursing Division” , Hadassah Mount Scopus Medical Centre Jerusuleum Israel. Int, J.H.Lare Qual Assur Inc Leadesh H.serv. 2004:178(2-3):75-80

23. Sinclain L et.al, “Wound Ostomy Continence Nursing” Master’s Nursing Programme University of Calgary, J, 2004 Jan-Feb:31(1):43-50

24. Larcher Calirj M H, Miyasaki M Y Piper B ,”Brazil Ostomy Wound Management” Ribeira Preto School of Nursing, Nursing University of Sao Paulo, Ribeirao preto,Sao, 2003 Mar:49(3):54-63.

25. Ms.Diana Lobo“effectiveness of Individual Planned Teaching to the care givers on prevention of pressure sore in bed ridden patients admitted to Fr Muller Medical College Hospital, Mangalore”( Unpublished Masters of nursing Dissertation ,Rajiv Gandhi University of Health Science,Bangalore, Karnataka)2004.

9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE

11 NAME AND DESIGNATION OF

11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.3 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12 12.1 REMARKS OF THE PRINCIPAL

12.2 SIGNATURE