RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESrguhs.ac.in/cdc/onlinecdc/uploads/05_N111_7499.doc · Web...
Transcript of RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESrguhs.ac.in/cdc/onlinecdc/uploads/05_N111_7499.doc · Web...
A STUDY TO ASSESS THE EFFECTIVENESS OF
STRUCTURED TEACHING PROGRAMME ON THE KNOWLEDGE AND PRACTICE OF
3RD YEAR Bsc NURSING STUDENTS REGARDING THE MANAGEMENT OF DIFFERENT
TYPES OF NEONATAL JAUNDICE IN SELECTED
COLLEGES OF TUMKUR.
PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
Miss.KEERTHI D’COSTA
AKSHAYA COLLEGE OF NURSING S.I.T. MAIN ROAD ,TUMKUR. DECEMBER 2008
1
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.
1. Name of the Candidate
and address
: Ms. KEERTHI D’COSTAMsc Nursing I yearAkshaya College of NursingAshoknagar, 2nd CrossTumkur-572102Karnataka.
2. Name of the Institution : Akshaya College of Nursing.
3. Course of Study and Subject : Msc Nursing 1st yearPaediatric Nursing.
4. Date of Admission to Course :
5. Title of the Topic : “A study to assess the effectiveness of structured teaching programme on knowledge and practice of 3rd year Bsc nursing students regarding the management of different types of Neonatal jaundice in selected nursing colleges of Tumkur”.
.
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6. BRIEF RESUME OF THE INTENDED WORK.
INTRODUCTION
‘So I triumphed my passion sweeping through me, left me dry, left me with a
palsied heart and left me with a jaundiced eye’
- Lord Alfred Tennyson.
Jaundice also known as icterus, comes from the French word jaune, meaning
yellow. Jaundice is the yellowish discoloration of the skin, sclera (whites of the eyes)
and mucous membranes caused by hyperbilirubinemia.1
Hyperbilirubenemia subsequently causes increased levels of bilirubin in the
extra cellular fluids. Typically, the concentration of bilirubin in plasma must exceed
1.5 mg/ dl three times the usual value of approximately 0.5 mg/dl for the coloration to
be easily visible.1
It was believed that persons suffering from the medical condition jaundice
saw everything as yellow. By extension the jaundiced eye came to mean a prejudiced
view usually rather negative or critical.1
Neonatal jaundice is usually harmless, this condition is often seen in neonates
around 2nd day after birth, lasting until 8 days in normal birth and to around day 14 in
preterm births. Newborns frequently go through a brief period of jaundice right after
their birth. This is termed as PHYSIOLOGICAL JAUNDICE of newborn and is due
to immaturity of infants liver, if carefully monitored these newborns generally
improve within 48-72 hrs.2
Jaundice appearing within 24 hrs of birth persisting for more than 1 week in a
term infant or more than 2 weeks in preterm infant where there will be excessive red
cell haemolysis is called as PATHOLOGICAL JAUNDICE.2
3
In neonates benign jaundice tends to develop because of two factors-the
breakdown of fetal hemoglobin which is replaced with adult hemoglobin and
secondly the relatively immature hepatic metabolic pathways, which are unable to
conjugate and so excrete bilirubin as quickly as an adult. This causes accumulation
of bilirubin in blood leading to symptoms of jaundice. Prolonged neonatal jaundice is
serious and should be followed promptly.1
6.1 NEED FOR THE STUDY
Jaundice is presumably a consequence of metabolic and physiological
adjustments after birth. The raised serum bilirubin normally drops to a low level
without any interventions in some cases whereas other requires prompt management.
Neonatal jaundice is the risk factor for many complications. Normal bilirubin value
should be more than 2mg/dl. A value of more than 5mg/dl is considered high.
Jaundice appears on 2nd and third day and disappears by 7th-10th day, a rise of 12mg/dl
in term neonates is seen in physiological range and jaundice appearing within 24hours
of birth with a rise of 15mg/dl in preterm and 12mg/dl in term neonates is seen in
pathological jaundice.2
A study conducted to estimate the causes of neonatal death where
data was collected from 44 countries reported that the causes for neonatal death
varied substantially and the major cause detected where: infections such as sepsis,
pneumonia, tetanus, diarrhea in 52% preterm birth, with deficiency diseases in 28%
and birth asphyxia in 23%. 3
A study was conducted to evaluate the etiology of indirect
hyperbilirubenemia and prevalence of glucose-6 phosphate dehydrogenace deficiency
in newborns. Out of 159(42.3%) boys and 217 (57.7%) girls, the prevalence of
glucose-6 phosphate dehydrogenace deficiency was in 59(15.7%) neonates, ABO
incompatibility in 14(3.7%) neonates, Rh incompatibility in 2(0.5%) neonates.4
4
A Study was conducted to overview the prevalence of neonatal jaundice in
neonatal intensive care unit of Koirala institute of health sciences in India. Among
293 neonates including 201 males and 92 females admitted: increased prevalence of
the disease was seen in 30% premature neonates, 29% of birth asphyxiated babies,
23% in respiratory distress babies.5
Apart from the above-mentioned studies neonatal jaundice can also result in
many complications. Prolonged hyperbilirubinemia can result into chronic bilirubin
encephalopathy, a brain damaging condition called KERNICTERUS. An effect of
kernicterus is fever. A study conducted on a male full term neonate with
hyperbilirubinemia at the age of 4 days displayed symptoms of increased lethargy,
refusal to eat and had fever.6
Another effect of kernicterus is seizures. The neonatal unit at allied hospital
Faisalabad studied 200 neonates of either gender who presented seizure during the
hospital stay from April 2003 to June 2004. The cause of seizure was evaluated and
one cause of seizure was kernicterus.4.5percentage or nine neonates displayed
seizures caused by kernicterus.7
High-pitched crying is also an effect of kernicterus. Scientists used a
computer to record and measured cranial nerves 8, 9 and 12. 50 infants were divided
into two groups equally depending upon bilirubin concentrations. Of the 50 infants,
43 had tracings of high-pitched crying. Neonatal jaundice is also risk factor for
hearing loss.8
From the above data the potentially correctable causes are:
Underestimating the severity of jaundice by clinical (i.e. visual) assessment.
Lack of concern regarding presence of jaundice.
Failure to recognize the presence of risk factors for hyperbilirubenimia.
Early discharge with no follow-up.9
5
From the above studies and if the above mentioned potential correctable
causes are seriously considered the incidence of Neonatal jaundice can be reduced.
Student nurses during their clinical training if develops concern and proper
knowledge about the causes, severity of jaundice and implements proper measures the
newborn will be protected from the risk of complications. Today’s student nurses are
tomorrow’s staff nurses and their knowledge will help in the prevention of
complications of jaundice. As 3rd year Bsc nursing student’s study child health
nursing, it is the base to construct their knowledge, so the investigator felt the need to
take up the study.
6.2 REVIEW OF LITERATURE.
The reviews of literature are presented under the following headings.
Risk factors and prevalence of hyperbilirubenemia.
Incidence and causes of Neonatal jaundice.
Awareness of neonatal jaundice.
Knowledge, practice of Neonatal jaundice.
Prevention of neonatal jaundice.
Management of Neonatal Jaundice.
Complications of neonatal jaundice.
RISK FACTORS AND PREVALANCE OF NEONATAL JAUNDICE.
RISK FACTORS
A study was conducted on “prevalence and risk factor of
hyperbilirubenemia” and the identified risk factors included Rh and ABO
incompatibility, glucose-6-phosphate dehydrogenase (G-6PD) deficiency and
elevated transcutaneous bilirubin level. G-6-PD deficiency occurrence was seen in
11-13% of blacks and was more common in immigrants from the Mediterranean
countries and Southeast Asia. These causes were associated with kernicterus in
United States also.10
6
EFFECT OF EARLY HOSPITAL DISCHARGE
A study was conducted on “early newborn hospital discharge and
readmission for mild and severe hyperbilirubenimia” in Washington. The result
showed that 750 infants readmissions to the hospital for jaundice in first 2 weeks of
life and revealed infants discharged from the hospital early were at increased risk for
jaundice. 11
Another study conducted on “early discharge of newborns: what problems
to anticipate” among 913 neonates, 42 presented the complications and among them
four required urgent neonatal care. The most common complication was
hyperbilirubinemia and 23 newborns were treated with phototherapy.12
INCIDENCE AND CAUSES OF NEONATAL JAUNDICE.
In Full Term Neonates.
A study was conducted in Canada on “Incidence and causes of severe
Neonatal hyperbilirubenemia” and out of 367 cases reported, 258 were confirmed to
be severe neonatal hyperbilirubenemia for an estimated incidence of one in 2480 live
births. Causes identified in 93 cases included ABO incompatibility, glucose 6-
Phosphate dehydrogenase deficiency, antibody incompatibility and hereditary
spherocytosis. The mean peak bilirubin level reported was 471 mol/l. Fifty-seven
infants underwent an exchange transfusion. 185 infants were readmitted to hospital
121 of them were within 5 days of age. 13
In Low Birth Weight Infants
A study was conducted on 94 preterm very low birth weight infants and
determined that the mean daily bilirubin values peaking on 4th day of life at
188.1 mol/l. 28 infants developed hyperbilirubenemia and they were exposed to
phototherapy. When individual peak bilirubin values were evaluated the overall peak
values was 213.9 mol/l occurring at 4.81 days. All the infants remained well and
progressed satisfactorily ‘Healthy’. Thus very low birth weight infant experience a
7
much greater incidence and severity of neonatal jaundice than mature with the same
clinical status.14
Incidence in Nether land.
A study was conducted on “ glucose- 6- phosphate dehydrogenase
deficiency: clinical presentation and eliciting factors” showed that glucose- 6-
phosphate dehydrogenase deficiency is most common enzymatic disorder of red
blood cells in humans which increased the incidence of neonatal jaundice. It also
showed its increased prevalence in Netherlands due to immigrants from the Middle
East and Africa.15
Causes
A study was conducted in panama to detect the case of Kernicterus in
glucose- 6- phosphate dehydrogenase deficient newborn clothed in naphthalene-
impregnated garments which showed a reduced psychomotor development, neuro
sensory hypoacousia, absence of speech and poor reflex of the pupils to light. The
study tells, as the use of naphthalene in stored clothes is a common practice, glucose-
6- phosphate dehydrogenase testing in neonatal screening could prevent severe
neonatal consequences.16
General
A Study was conducted on “jaundice in newborns” which showed that
hyperbilirubenemia is the commonest morbidity in neonatal period and 5-10% of all
newborns require interventions for pathological jaundice it also showed neonates on
exclusive breast feeding had a different pattern and degree of jaundice as compared to
artificially fed babies the study advised to provide separate guidelines for the
management of jaundice in sick term babies, preterm and low birth weight babies. 17
8
AWARENESS OF NEONATAL JAUNDICE.
o In Mediterranean region.
A study was conducted on “Awareness of Neonatal jaundice in
Mediterranean region” which observed adequate knowledge of the participants in
many aspects of Neonatal jaundice but also revealed some misconceptions of the
respondents in the use of medications and management of Neonatal jaundice. The
study called for a well-structured health education programmes stressing on such
misconceptions.18
o In family health care professionals.
A study conducted on yellow alerts showed the increased incidence for
neonatal jaundice is because the families have been falsely reassured that their baby’s
jaundice is normal, as the family health care professionals are unaware to identify
neonatal jaundice. It reviews the importance of awareness of family health care
professionals to identify the infants with liver diseases.19
KNOWLEDGE AND PRACTICE OF NEONATAL JAUNDICE
Knowledge and Practice by the Mothers.
A study was conducted on Iranian mothers with icteric newborn to assess their
knowledge and practice. About 77% of the mothers had moderate to high-level
knowledge of Neonatal jaundice. Approximately 1/3rd of the mothers consulted
physician within 24hrs of appearance of jaundice and 13.8% mothers declared that
they waited and managed their children with traditional remedies until they sought
medical advices. 32.2% of mothers discontinued feeding their icteric offspring with
colored foods and colostrums. The study determined poor knowledge of Iranian
mothers with incomparable level of related practice.20
9
Knowledge and practice by the nurses.
A study was conducted on ‘Neonatal jaundice and its management:
Knowledge, attitude and practice of community health workers in Nigeria’. 66 of 71
health workers participated in survey 34 respondents defined neonatal jaundice
correctly, 26 responses were either partially correct or incorrect while six people did
not respond. Thus the researcher concluded that knowledge gaps exists among
primary health workers concerning neonatal jaundice and its management and they
recommended that regular training, workshops or seminars should be conducted to
bridge these gaps.21
Pediatricians’ practices.
A study was conducted to evaluate “Pediatricians practices and believes
regarding management of neonatal hyperbilirubenemia” and identified that
pediatricians utilized very low laboratory diagnosis for quantification of jaundice and
they also underestimated the risk factors that contribute to the development of severe
hyperbilirubenemia. They also initiated phototherapy at lower parameters than the
recommended treatment parameters.22
PREVENTION OF NEONATAL JAUNDICE.
A study was conducted on “a practical approach to neonatal jaundice” showed
that kernicterus and neurologic sequence caused by severe hyperbilirubenemia are
preventable conditions. Primary prevention includes ensuring adequate feeding.
Secondary prevention is achieved by vigilant monitoring of neonatal jaundice. Thus,
the study showed if a structured and practical approach is applied to the identification
and care of infants with jaundice could facilitate its prevention.23
MANAGEMENT OF NEONATAL JAUNDICE.
10
Phototherapy.
A study was conducted for the specific recommendations on the
initiation of phototherapy and guided that the thresholds at which phototherapy is
used should be adjusted according to gestational age, birth weight and age of
jaundiced babies. They also suggested that phototherapy could be taken off when the
serum bilirubin drops below 185 micro mol/L on two consecutive readings for a
minimum duration of 24 hours.24
Effect of phototherapy
A study was conducted on neonates with hyperbilirubenemia to find out
the possible relation between phototherapy and DNA damage. The study included 33
full term newborns with non-physiologic jaundice and 14 healthy newborns with
physiological jaundice as controls. Phototherapy was performed with an array of six
fluorescent lamps producing radiation with wavelengths of 480-520nm. DNA damage
in lymphocytes was determined by use of alkaline comet assay. It showed increased
incidence of DNA damage with the increased duration of phototherapy.25
Pharmacotherapy.
A study was conducted on “An old traditional herbal remedy for Neonatal
jaundice with a newly identified risk” in Hong Kong. Result indicated that Yen-Chen
(Artemisia Scoparia) is very popular intravenous herbal preparation that displaces
bilirubin from its protein binding free bilirubin liberated in this process increases the
risk of brain damage in jaundiced infants. Therefore, the use of traditional herbal
therapies should be strongly discouraged in neonates. They suggested the use of
medical preparations such as Phenobarbital therapy that induces hepatic microsomal
enzymes and increases bilirubin conjugation and excretion. 26
Exchange transfusion.
Guidelines for exchange transfusion
11
A study was conducted on “Guidelines for exchange transfusion in infants
35 or more weeks of gestation” and suggested if total serum bilirubin (TSB) raises
above levels despite phototherapy in readmitted infants exchange transfusion may be
indicated. The blood should be sent for immediate type and only trained personnel in
a neonatal intensive care unit with full monitoring and resuscitation capabilities
should perform cross matching and exchange transfusion. 27
Exchange transfusion using Peripheral vessels
A study was conducted on “exchange transfusion using peripheral vessels”
out of 123 newborns that underwent exchange transfusion, 24 were performed via
umbilical vein and 99 via peripheral vessel method. It showed that severe adverse
effects occurred in umbilical vein group than peripheral vessels group. Thus, the
study revealed peripheral veins and arteries are safe and effective for exchange
transfusion in newborn infants.28
COMPLICATIONS OF NEONATAL JAUNDICE
A Study was conducted on “unbound bilirubin concentration is associated
with abnormal automated auditory brainstem response for jaundiced newborns” out of
44 infants with proximate total bilirubin concentration, 4 of them showed
neurotoxicity, 5 showed the possibility of deafness and remaining exhibited abnormal
automated auditory brainstem responses.29
6.3 STATEMENT OF THE PROBLEM.
12
6.4 OBJECTIVES OF THE STUDY
To assess the knowledge of the students regarding management of
different types of Neonatal jaundice.
To identify the practices of the students regarding management of
different types of Neonatal jaundice.
To evaluate the effectiveness of structured teaching programme on
knowledge and practice regarding management of different types of
Neonatal jaundice.
To find the correlation between knowledge and practice of students
regarding the management of different types of neonatal jaundice.
To associate the selected demographic data of students with their
knowledge and practice.
6.5 OPERATIONAL DEFINITONS.
ASSESS
It refers to the statistical measurement of knowledge of the students on
questionnaire regarding management of different types of Neonatal jaundice.
EFFECTIVENESS
It is the significant improvement in knowledge and practice among the
students after the implementation of structured teaching programme as evidenced by
the differences in the pretest and post test scores.
STRUCTURED TEACHING PROGRAMME.
It refers to systematically developed instructions designed for a group of
students to provide information regarding management of different types of Neonatal
jaundice.
13
KNOWLEDGE
It refers to the responses of the respondent to the knowledge regarding
management of different types of Neonatal jaundice.
PRACTICE
It refers to the action of the students in relation to management of different
types of Neonatal jaundice.
STUDENTS.
III year Bsc nursing students those who have not appeared for the final exams.
MANAGEMENT
Continue to function, to progress or succeed, usually despite difficulty. In this study
it is refers to the effective use or application of,
Phototherapy
Pharmacotherapy
Exchange blood transfusion
.
NEONATAL JAUNDICE
Yellowish discoloration of the skin and mucosa caused by excessive
accumulation of bilirubin is neonatal jaundice. Different types are;
Physiological jaundice: usually harmless noticed
during 3-5 days of life.
Pathological jaundice: here bilirubin will be seen
in the blood which affects babies brain cells
leading to complications..
Not enough breast milk jaundice: seen in poorly
breastfed babies where inadequate breast milk
increases bilirubin in blood
14
Inadequate liver function: Jaundice which
occurs due to infections of the liver
Jaundice of prematurity: seen in preterm babies
Breast milk jaundice: seen in inadequately
breastfed babies.
6.6 ASSUMPTIONS:
It is assumed that 3rd year Bsc nursing students have some knowledge
about management of different types of neonatal jaundice.
Structured teaching programme will enhance the knowledge and practice
of 3rd year Bsc nursing students regarding the management of different
types of neonatal jaundice.
6.6 HYPOTHESIS
H1: there will be significant relationship between knowledge and practice
regarding management of different types of neonatal jaundice
among 3rd year Bsc nursing students.
H2: there will be significant relationship between structured teaching
programme and the changes in knowledge and practice among
3rd year students regarding management of different types of
neonatal Jaundice.
H3: there will be significant association of selected demographic variables
with knowledge and practice of 3rd year Bsc students regarding the
management of different types of neonatal jaundice.
15
7 MATERIALS AND METHODS
7.1 SOURCES OF DATA
Research Design : Quasi-experimental. One group pretest and
. post test designs.
Setting of the Study : Akshaya college of nursing and
Anirudh college of nursing
Population : students of 3rd year Bsc nursing in selected
Nursing colleges of Tumkur.
Sample size :60 subjects
Sampling Technique : Simple random sampling
Selected variables.
Demographic variable – age, sex, education etc
Dependent variable – knowledge & practice
Independent variable – structured teaching programme
Sampling criteria
Inclusion Criteria
Students studying in III year Bsc Nursing in selected
nursing colleges.
Students who can understand either English or
Kannada.
Students who are willing to participate in the study.
Exclusion criteria
Students who are not willing to participate
Students who do not understand either English
or Kannada.
Students who are not available at the time of
data collection
16
7.2 METHODS OF DATA COLLECTION
Tools of data collection:
After obtaining the permission from concerned authorities, the investigator
will introduce herself to the study subjects and explains the purpose of the
study. Informed consent will be obtained from the study samples and the
data will be collected by interview method using structured questionnaire
Descripition of the tool
Part A : Proforma for collecting demographic data
Part B : Structured questionnaire to assess the knowledge and
Practice regarding the management of different types of
Neonatal Jaundice.
7.2.1 Methods of data analysis and interpretation
Data will be analyzed according to the objectives of the study using
descriptive and inferential statistics and will be presented in the form of tables, graphs
and diagrams
7.2.2 Duration of the Study : 6 weeks
7.3 Does the study require any investigation or intervention to be conducted
on the patients or other human being or animals if so please describe
briefly.
NO
7.4 Has ethical clearance been obtained from your institution in case of the
above?
NA.
17
8. REFERENCES
1. Annama Jacob, “comprehensive textbook of midwifery” jaypee
publications, Page no: 551-555
2. Dutta D C, “Text book of obstetrics” Hilular konnar publications 6 th
edition 2004 page no: 477-480.
3. Joy E Lawn, Katarzyna, Wilczynska “Estimating the cause of neonatal
death” newyork, 22 feb 2006.
4. Kooshat , Rafizadehview B, “ Evaluation of indirect hyperbilirubenemia
and prevalence of glouse-6- phosphate dehydrogenace deficiency” 2005
5. Koirala institute of health sciences “Overview of cases and prevalence of
neonatal jaundice in neonatal intensive care units” Nepal june 8th 2006
133-35.
6. www. Wilkipedia.com
7. www.who.com
8. Poland Ronald “Journal of acute bilirubin encephalopathy” American
academy of paediatrics
9. Shashank and V.Parulekas “textbook for midwifery” Vora medical
publications 2nd edition, Page no: 483-488.
10. Friedman L “Prevalance and risk factors of hyperbilirubenemia” May
2004
11. Jacqueline grupp, Phelan, James.A, Taylor.M.D, “Early newborn hospital
discharge and readmission for mild and severe jaundice” 1994
12. Straizek H, Vieux R, Hubert C, Miton A, “Early discharge of newborns
what problems to anticipate” June 2008.
13. Michael saro, Douglas Campbell “Incidence and causes of neonatal
hyperbilirubinemia” Canada 2006.
14. Tan K L, “Incidence of neonatal hyperbilirubinemia in low birth weight
babies” 2006.
18
15. .Dors.N, Rodriguez Pereira.R, Yan Zwieten R, Fijnvandraat.K, Peters.M,
“glucose- 6- phosphate dehydrogenase deficiency: Clinical presentation
and eliciting factors”, May 2008.
16. . De Gurrola G C, Arauz J J, Duran E, Aguilar Medina M, Ramos Payan ,
“Kernictures by glucose- 6- phosphate dehydrogenase deficiency” Panama
May 2008.
17. Mishra.S, Agarwal.R, “jaundice in newborns” pub med, Feb.: 2008.
18. Friedman L “ Prevalance and risk factors of hyperbilirubenemia” 2003
19. Tizzard.S, Yiannouzis.K, “Yellow Alert: how to identify neonatal
jaundice” pediatric liver center, London, April 2008
20. Amirshaghaghi.A, Ghabili.k, “Neonatal jaundice: knowledge, practice of
Iranian mother with icteric newborn” 2004
21. Ogunfowora, “neonatal jaundice and its management: knowledge,
attitude and practice of community health workers in Nigeria” Biomed
central journal’2006
22. Anna petrova, Rajeev Mehta, Gillian Birchwood, Barbara ostfeld,
“management of neonatal hyperbilirubinemia: pediatricians practices”
2006
23. Moerschel. S.K, Cianciaruso.L.B, Tracy.L.R, “A Practical approach to
neonatal jaundice” department of family medicine, Virginia; USA, May
2008.
24.. Lee at A,”phototherapy in management of neonatal management”2001
25. Tatli.M.M, Minnet.C, Kocyigit.A, Karadag.A, “Phototherapy increases
DNA damage in lymphocytes of hyperbilirubinemia neonates” June
2008.
26. Yung.c.y, “old traditional herbal remedy for neonatal jaundice with a
newly identified risk” 1993
27. American academy of pediatrics, subcommittee on hyperbilirubinemia
“management of hyperbilirubinemia in the newborn infant 35 or more
weeks of gestation” 2004
19
28. Chen.H.N, Lee.M.C, Tsao. L.Y, “Exchange transfusion using peripheral
Vessels is safe and effective in newborn infants” Department of
pediatrics, Taiwan: Dec 2007
29. Ahlfors C E, Parker A E “ Unbound bilirubin concentration and
automated brainstem response for jaundiced neonates” May 2008
20
9. Signature of the candidate :
10. Remarks of the guide :
11. Name and designation of : [in block letters]
11.1. Guide : 11.2. Signature :
11.3. Co-Guide [if any] :
11.4. Signature :
11.5. Head of the department :
11.6. Signature : 12 12.1. Remarks of the chairman
and principal :
12.2. Signature :
21