PROFORMA FOR THE REGISTRATION OF SUBJECT FOR DISSERTATION

“ASSESS THE EFFECTIVENESS OF FOOT MASSAGE

(REFLEXOLOGY) TO REDUCE PAIN AMONG CANCER

PATIENTS WHO ARE UNDERGOING RADIATION

THERAPY AT SELECTED HOSPITALS, TUMKUR.”

SUBMITTED BY;

MS. RAJI M VARGHESE

MEDICAL SURGICAL NURSING

SHRIDEVI COLLEGE OF NURSING

SIRA ROAD, LINGAPURA

TUMKUR

2013-15

RA J I V G AND H I UN I V E R S I TY O F HE A L T H S C I E NC E S

BE NGALURU, KAR NATAKA

P R O F OR M A F O R T H E R EG I ST R A TI O N O F

S U B J E C T FO R D I SSE R TA T I O N

1 NAME OF

CANDIDATE AND

ADDRESS

MS. RAJI M VARGHESE

1 YEAR M.Sc NURSING

SHRIDEVI COLLEGE OF

NURSING,

SIRA ROAD, LINGAPURA

TUMKUR

2 NAME OF THE

INSTITUTION

SHRIDEVI COLLEGE OF

NURSING

3 COURSE STUDY AND

SUBJECT

I YEAR M.SC. NURSING

MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION

TO COURSE 01-06-2013

5 TITLE OF THE TOPIC “ASSESS THE EFFECTIVENESS

OF FOOT MASSAGE

(REFLEXOLOGY) TO REDUCE

PAIN AMONG CANCER

PATIENTS WHO ARE

UNDERGOING RADIATION

THERAPY AT SELECTED

HOSPITALS, TUMKUR.”

6. BRIEF RESUME OF THE INTENDED WORK

Introduction

“Pain is inevitable, suffering is optional.”

William Rogers

Cancer known medically as a malignant neoplasm, is a broad group of various

diseases, all involving unregulated cell growth. In cancer, cells divide and grow

uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer

may also spread to more distant parts of the body through the lymphatic system or

bloodstream. Many things are known to increase the risk of cancer, including tobacco use,

dietary factors, certain infections, exposure to radiation, lack of physical activity, obesity,

and environmental pollutants. These factors can directly damage genes or combine with

existing genetic faults within cells to cause cancerous mutations.

WHO (2008) has predicted that cancer would overtake heart disease as leading

killer disease. About 7.6 million people died of cancer in 2008, and about 12.4 million new

cases are diagnosed each year. 15 % of newly reported cancers were in developing

countries; by 2030 it will rise to 70%. Worldwide almost two thirds of the 7.6 million

deaths from cancer occur every year in low and middle income countries. Overall fatality

from cancer is estimated to be 75 % in countries of low income, 72% in countries of low

middle income, 64% in high middle income and 46% in countries of High income1

While cancer can affect people of all ages, the risk of developing cancer generally

increases with age. Risk rates are rising as more people live to an old age and as mass

lifestyle changes occur in the developing world. According to Indian cancer statistics, India

has one of the highest cancer rates in the world. In India, about a million new cancer cases

are diagnosed every year, and that number is projected to triple in the next 20 years.

Seven warning signs of cancer such as Unusual bleeding/discharge, A sore which

does not heal, Change in bowel or bladder habits, Lump in breast or other part of the body,

Nagging cough, Obvious change in moles, Difficulty in swallowing about cancer created

awareness among the people, certain cancer can’t be find in its earlier stage.

General signs and symptoms of cancer include unexplained weight loss, fatigue, and pain

and skin changes. Approximately 30% to 50% of people with cancer experience pain while

undergoing treatment, and 50% to 70% of people with cancer experience pain at advanced

stage. It is reported that more than 12,900 elderly cancer patients reported pain depends on

many factors such as the type of cancer, the stage of the disease, and the patient’s

tolerance2.

Pain is one of the most common symptoms in patients with cancer: it is certainly

the most feared. Pain occurs in two-third of patients with advanced cancer. Pain in cancer

may arise from a tumor compressing or infiltrating tissue; from treatments and diagnostic

procedures; or from skin, nerve and other changes caused by the body's immune response

or hormones released by the tumor. Most acute pain is caused by treatment or diagnostic

procedures, though radiotherapy and chemotherapy may produce painful conditions that

persist long after treatment has ended. It is reported that the 40% to 50% cancer patients

with pain, reported it as moderate to severe and another 25% to 30% described it as very

severe3.

Cancer pain can be eliminated or well controlled in 80 to 90 per cent of cases by the

use of drugs (such as morphine) and other interventions, but nearly one in two patients

receives less-than-optimal care. Treatment guidelines for the use of drugs in the

management of cancer pain have been published by the World Health Organization and

other organizations. Healthcare professionals have an ethical obligation to ensure that,

whenever possible, the patient or patient's guardian is well-informed about the risks and

benefits associated with their pain management options. Adequate pain management may

sometimes slightly shorten a dying patient's life.

There are many ways to relieve pain, from drugs to surgery. Treatment may vary

from individual to individual, depending on the type and severity of pain, risk factors

involved with using a particular treatment, and personal preference. Opioids, a common

treatment for pain, can lead to dependence, addiction and tolerance. Pain is often under

treated. Some of the most common treatments are analgesic therapy, WHO three-step

analgesic ladder that is If pain occurs, there should be prompt oral administration of drugs

in the following order: non-opioids (aspirin and paracetamol); then, as necessary, mild

opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To

calm fears and anxiety, additional drugs – “adjuvants” – should be used4.

All cancer patients are using conventional medical treatment offered by modern

oncology to fight cancer. At the same time more and more patients are using

complementary and alternative medicine (CAM) alone or in combination with the

traditional treatment in order to improve the quality of life and relieve secondary

symptoms.

Foot massage is a complimentary therapy that has great potential use by the nurses

in a multidisciplinary pain management programme. Because nurses are the only person

who provide care to the patients round o clock. Foot massage is the process of gentle but

firm manipulation to feet to stimulate specific reflex points of the body. This is based on

the reflexes running along the body which terminate in the feet and that the body’s organs

and systems are reflected onto the surface of the skin. Massage acts like an analgesic and

inhibits those pain signals from being transmitted to the brain. It is also thought that

massage helps the body to release endorphins. Foot massage can be given at anytime,

anywhere, there is no time limit, and it won’t produce any side effects. Foot massage is an

effective pain relieving therapy for the patient with cancer pain, recommended the use of

foot massage as a complementary therapy and as a relatively simple nursing intervention

for patients experiencing pain or nausea related to the cancer experience5.

6.1 NEED FOR THE STUDY

Cancer is a global problem and has a major impact on life, requiring chemotherapy

and radiation therapy as an important treatment measure. Many cancer patients seek

medical help at terminal stage. The cancer related pain is still one of the critical problems

of modern oncology. In India, about a million new cancer cases are diagnosed every year,

and that number is projected to triple in the next 20 years. Nearly two-thirds of

all cancer patients will receive radiation therapy during their illness6.

Radiation therapy use of ionizing radiation, generally as part of cancer treatment to

control or kill malignant cells. It may also be used as part of adjuvant therapy, to prevent

tumor recurrence after surgery to remove a primary malignant tumor (for example, early

stages of breast cancer). Radiation therapy is synergistic with chemotherapy, and has been

used before, during, and after chemotherapy in susceptible cancers.

Radiation therapy involves the use of ionizing radiation in an attempt to either cure

or improve the symptoms of cancer. Ionizing radiation works by damaging the DNA of

exposed tissue leading to cellular death. To spare normal tissues (such as skin or organs

which radiation must pass through in order to treat the tumor), shaped radiation beams are

aimed from several angles of exposure to intersect at the tumor, providing a much larger

absorbed dose there than in the surrounding healthy tissue. It is used in about half of all

cases and the radiation can be from either internal sources in the form of brachytherapy or

external sources. Radiation is typically used in addition to surgery and or chemotherapy but

for certain types of cancer such as early head and neck cancer may be used alone. For

painful bone metastasis it has been found to be effective in about 70% of people. The

amount of radiation used in radiation therapy is measured in gray (Gy), and varies

depending on the type and stage of cancer being treated. The following are the statistics of

radiation therapy in Radiology department at Rajiv Gandhi Government General Hospital,

Chennai.

YEAR NEW CASES OLD CASES RADIATION THERAPY

RECEIVED

2008 986 4532 14340

2009 1093 6540 16782

2010 1494 7379 17170

2011 1946 9189 28049

2012 2013 10856 28889

Side effects from radiation are usually limited to the area of the patient's body that

is under treatment. The main side effects reported are fatigue and skin irritation. Acute side

effects are Nausea and vomiting, damage to the epithelial surfaces, pain, Mouth, throat and

stomach sores Intestinal discomfort Swelling and Infertility. Late side effects are Fibrosis,

epilation, dryness, lymphedema, Heart disease, and Radiation proctitis7.

Cancer pain often leads to debilitation, diminished quality of life, and depression.

Effective pain control is best achieved through a combination of both pharmaceutical and

non-pharmaceutical therapies. Pharmaceutical management has been the primary means of

providing relief from pain. Analgesics have maximum effective dose; increasing the dose

cannot increase pain relief, but may increase side effects. Tolerance also may occur when

larger doses of medicines are needed to provide the same amount of pain relief as the

previous smaller dose. Although pharmaceutical medications continue to serve as a major

contributor to pain management, non-pharmaceutical techniques are increasingly used to

provide pain relief.

Reflexology has been used for centuries. It is thought to have originated in the

ancient Egypt. It is not a medical approach in the usual sense of the word but rather a

holistic approach that is complementary to more traditional conventional medicine. Foot

massage is the manipulation of the soft tissue of whole body areas to bring about

generalised improvements in health, such as relief of muscular aches and pains. or specific

physical benefits, such as relaxation or improved sleep,

 It is a touch therapy which works by applying pressure and massage to certain

areas on feet and hands (it is more common to treat feet than hands). The reflexologists

believe that 'reflex areas' in the feet related to individual parts of body. And thus by

applying pressure to certain reflex areas, certain bodily functions or corresponding organs

can be stimulated. It is one of the most popular types of complementary therapies in the

UK among cancer patients. As it is a complementary therapy it should not be used as an

alternative to conventional medicine but rather as an additional therapy to conventional

treatment. Foot massage can reduces the intake of pain relieving medications among the

cancer patients8.

The human body is divided into different zones represented by a point in the foot or

hand. Feet and hands have nerve endings. Reflexology works by stimulating these nerve

endings which results in promoting relaxation, improving circulation, stimulating vital

organs in the body and encouraging the body's natural healing processes. Unlike

conventional medicine, reflexology works on the underlying problems within the body

through the body's nervous system.

Reflexology aims to help muscles relax and encourage the body to use its own

resources more effectively. As a result, reflexology is believed to help with a wide variety

of conditions which including:

pain

stress and anxiety

depressed mood

Reflexology will not lead serious health problems. If it is used regularly it will enhance

other treatments by keeping the circulation stimulated and the lymph system active.

Individual also experience feelings of vitality and well-being after reflexology

treatment which encourages the healing process throughout the body.

6.2 REVIEW OF LITERATURE

The review of literature is defined as broad, comprehensive in-depth, systematic

and critical review of scholarly publications, unpublished scholarly print materials,

audio visual materials and personal communications.

SECTION A: REVIEWS RELATED TO CANCER PAIN AND TREATMENT

American Cancer Institute(March2012) “This report demonstrates the value of cancer

registry data in identifying the links among physical inactivity, obesity, and cancer,” said CDC

Director Thomas R. Frieden, M.D. “It also provides an update of how we are progressing in the

fight against cancer by identifying populations with unhealthy behaviors and high cancer rates that

can benefit from targeted, lifesaving strategies, and interventions to improve lifestyle behaviors and

support healthy environments.”

Wang HL, Kroenke K (2011) Assessed the cross-sectional association between cancer-

related pain and disability is well established, their longitudinal relationship has been less studied.

Disability over 12 months in patients with cancer-related pain is predicted by changes in pain

severity over time. Results suggest that effective pain management may reduce subsequent

disability among cancer survivors9.

PubMed (2011) A trial of Sativex for cancer related pain. There are different ways to treat

cancer pain, including strong painkillers called opioids. In this trial, they are looking at a drug

called Sativex. The main active ingredients of Sativex are tetrahydrocannabinol (THC) and

cannabidiol (CBD). Both of these molecules come from the cannabis (marijuana) plant. But

sometimes, even opioids and other drugs cannot completely control the pain. Researchers are

looking for ways to help people in this situation10.

Constantini.M, et.al., (2009) reported a mortality follow-back survey to determine the

prevalence, distress, management and relief of pain during last 3 months of cancer patients life of a

representative sample of dying cancer patients. Care givers were interviewed, after the patient’s

death, about pain experienced by the patients. According to care givers, 82.3% (95% to 79.9% to

84.4%) patients experienced pain and 61.0% (95% CI 57.9% -64.0%) very stressing pain, the

younger population experienced a higher prevalence of pain in respect to their patients(P<0.01)11.

Tsai Sc (2009) studied the incidence and factors related to Emergency Department visits

by cancer patients with pain complaints during a year period. Medical charts by stratified random

sampling included 1179 ED visits by 1026 cancer patients were actively reviewed. Pain was the

most common reason for emergency department visits by cancer patients12.

Sheeba. C. (2007) reported selected acute symptoms experienced by cancer patients and

the feasibility of a structured training programme on symptom management of 30 cancer patients

receiving palliative home care in and around Vellore using purposive sampling. Pain measured

using numerical pain rating scale and it showed that majority of the terminally ill cancer patients

experienced pain (80%)13.

Deimling GT, Bowman KF and Wagner LJ (2007) observed the fatigue and pain

reported by survivors of breast, prostate, and colorectal cancer selected by random sampling in case

Western Reserve University, USA. Importance of cancer and age-related factors as correlates of

pain and fatigue as well as the relationship between pain and fatigue and functional difficulty. The

results were examined of multivariate analysis indicated that the pain, energy level, and weakness

reported by older adult cancer survivors are more strongly related to age-related factors than they

are to cancer-related factors14.

Edrington, et al., (2007) reported a study to examine of pain in these cancer patients. Pub

med, psych info and Google scholar searches were conducted years 1996 to 2005 for all research in

English. The literature search and review science lists from the studies identified the 24 studies that

were used in the review. Most of the descriptive co- relational studies evaluated the physiologic

and sensory dimensions of the experience reported moderate to severe pain and that pain interfered

with their normal rate and mood. P<.001)15.

Winnie Dawson, MA (2007) observed Pain is one of the most common and most feared

symptoms in patients with cancer. Toward the end of life up to 80% of patients with cancer may

experience severe pain. Documents in this section focus on pain control and associated symptom

management via pharmacotherapy’s, nonpharmacologic strategies, and/or complementary

approaches during cancer care16.

Robb KA, Williams JE (2006) A large proportion of patients may develop chronic pain

following cancer treatments such as surgery, radiotherapy, or chemotherapy. These patients can

experience significant levels of physical and psychological morbidity. A combination of physical

and psychological techniques were adapted from previous work in chronic benign pain and

implemented by two therapists. Interventions included education, relaxation, exercise training, and

goal setting. There was a significant trend toward improvement in many variables, including

anxiety and depression (P < .01), fitness (walking: P < .05), and coping with pain (P < .01)17.

Kalyani.V.C.(2006) conducted an experimental study to assess the effectiveness of music

therapy on pain, anxiety and selected factors in 30 cancer patients using purposive sampling

technique in Apollo hospitals Chennai by giving 2 sessions of 30 minutes music therapy for 5

consecutive days. The instruments used were demographic and clinical variables Performa, spiel

burger’s state anxiety sub scale, 0-10 point pain intensity scale and assessment tool on physiologic

variables. The pain of cancer patients was high before in comparison with scores after the music

therapy 18.

SECTION B: REVIEWS RELATED TO PAIN ASSESSMENT

Willianmson A, Hoggart B Birmingham, UK (2006) conducted a study on a review of

three commonly used pain rating scales, the visual analogue scale, the verbal rating scale and the

Numerical rating scale. All three pain-rating scales are valid, reliable and appropriate for use in

clinical practice, although the visual Analogue scale has more practical difficulties then the verbal

Rating Scale (or) the Numerical Rating scale. Numerical Rating Scale has good sensitivity and

generates data that can be statistically analyzed for audit purpose19.

Kane RL, Bershadsky B, Rockwood T et.al. USA (2005), conducted a study on Visual

Analog scale pain reporting was standardized. Whereas pain is frequently measured using a visual

Analog scale that can examine charge over short time interval in the same subject, such ratings are

not useful in analyzing differences across subjects. Results on individual variations in pain rating

were found to be independent of respondent age and gender, but were correlated with experience of

the event (or) behavior and with self-reported health status. A new scoring method that takes into

account these correlations is proposed. It concluded that it is possible to standardize VAS pain

ratings to compare pain between different populations20.

Randall et al (2004) conducted a study on comparison of the verbal rating scale and the

visual analog scale for pain assessment on 85 chronic pain patients by survey method at Louisiana

State University health sciences center. Data were analyzed with correlation analysis and students

assessment for Pearson correlation coefficient (r = 0.906) and p value (< 0.0001) showed excellent

correlation between the two, although VRS showed a tendency to be higher than VAS. The results

revealed that the VRS provides a useful alternative to the VAS scores in assessment of chronic

pain21.

SECTION C: REVIEWS RELATED TO FOOT MASSAGE

Faith Davis, BA (2012) Morton’s neuroma is a common cause of pain that radiates from

between the third and fourth metatarsals and which, when symptomatic, creates sensations of

burning or sharp pain and numbness on the forefoot. The client reported progressive change in the

character of the pain from burning and stabbing before the first session to a dull, pulsing sensation

after the third session. She also recorded a reduction in pain during exercise from a 5/10 to 0/10 (on

a scale where 10 is extreme pain)22.

Jeongsoon Lee, Misook Han (2011) evaluate the effectiveness of foot reflexology on

fatigue, sleep and pain. A systematic review and meta-analysis were conducted. This meta-analysis

indicates that foot reflexology is a useful nursing intervention to relieve fatigue, pain, and to

promote sleep. Further studies are needed to evaluate the effects of foot reflexology on outcome

variables other than fatigue, sleep and pain23.

6.3 STATEMENT OF THE PROBLEM

“A STUDY TO ASSESS THE EFFECTIVENESS OF FOOT MASSAGES

(REFLEXOLOGY) TO REDUCE PAIN AMONG CANCER PATIENTS WHO ARE

UNDERGOING RADIATION THERAPY AT SELECTED HOSPITALS,

TUMKUR.”

6.4 OBJECTIVES OF THE STUDY

1. Pre assessment of pain among experimental and control group

2. Post assessment of pain after foot massage among experimental group and

routine care control group.

3. To assess the effectiveness of foot massage between experimental and control

group

4. To associate the effectiveness of foot massage with the selected demographical

variables.

6.5 OPERATIONAL DEFINITIONS

Effectiveness: In this study, it refers to the extent in which foot massage have

impact on the reduction of pain which is assessed by Numerical pain rating scale.

Foot massage: foot massage refers to both the feet of the patient at various position

stroked gently and rhythmically by the techniques of Sweeping, Rubbing, Thumb

walking, Toe rotating, Kneading and Cupping about 20 minutes to attain a

relaxation response.

Pain: pain refers to an unpleasant sensation occurring in varying degrees of

severity as a consequence of cancer disease.

Cancer patients: Refer to those clients who were diagnosed to have malignancy by

the oncologists.

Radiation therapy: The treatment of cancer diseases by using x rays usually from

the cobalt source, to direct the proliferation of malignant cells by destroy or keep

them from reproducing.

6.6 HYPOTHESIS

The following hypotheses will be tested at 0.05 level of significance

H1: The Post assessment pain score of cancer patients who are undergoing

Radiation therapy in experimental group will be lower than that of cancer patients

in control group.

H2: There will be a significant association of the post assessment pain score of

cancer patients who are undergoing Radiation therapy with selected demographical

variables in experimental group.

.

6.7 ASSUMPTIONS

Cancer pain differs from patient to patient.

Non-pharmacological interventions are one of the means to reduce cancer pain in

patients undergoing radiation therapy.

6.8 VARIABLES UNDER STUDY

D e p e nd e nt V a r i a b l e s : Pain

I n d e p e n d e nt V a r i a bl e s : Foot massage

D e m o g r a p h ic V a r i a bl e s : Age, gender, marital status, educational status, type

of family, Family income, Type of family, Duration of the illness, Type of treatment.

6.9 DELIMITATIONS

The study is limited to the cancer patients who,

Will be present during the period of data collection.

Are willing to participate in the study.

The sample size is limited to 60 cancer patients.

Are in selected hospitals, Tumkur.

6.10 PILOT STUDY

The pilot study will be conducted with 6 cancer patients and who will be

excluded in the main study. The purpose of pilot study is to find out the feasibility of

conducting study and design on plan of statistical analysis. The findings of the pilot

study samples will not be included in main study.

7.0 MATERIALS AND METHODS

A written permission will be obtained from the concerned authority prior to

the onset of the study, the purpose of the study and method of data collection will be

explained to the participants and informed consent will be taken, confidentiality will

be assured to all subjects to get their co-operation. Data will be collected from 60

cancer patients in selected hospitals Tumkur as per the inclusion criteria for the study. At

the end subjects will be thanked for their co-operation during the study.

7.1 SOURCES OF DATA

Data will be collected from cancer patients who p resent a t the selected hospitals,

Tumkur.

RESEARCH DESIGNThe research design used for this study is quasi experimental two group pre

assessment and post assessment design.

GROUPPre

AssessmentIntervention

Post

Assessment

Experimental Group 01 X 02

Control group 03 ____ 04

01 – Pre assessment pain score in experimental group

02- Post Assessment pain score in Experimental group

X- Foot massage.

03- Pre assessment pain score in control group

04- Post assessment pain score in Control Group

RESEARCH APPROACH

Quantitative approach was used for this study

RESEARCH SETTING

The study will be conducted at selected hospitals, Tumkur.

POPULATION

Population in the study consists of cancer patients at selected hospitals,

Tumkur.

SAMPLE SIZE

Total sample of the study will consist of 60 cancer patients in selected

hospitals, Tumkur.

SAMPLE TECHNIQUE

In this study the convenient sampling technique was used.

SAMPLING CRITERIA

INCLUSION CRITERIA

Cancer patients who are undergoing radiation therapy

Cancer patients willing to receive foot massage

Patients with cancer irrespective of any site.

Both male and female of cancer patients.

Cancer patients who are able to understand Kannada.

EXCLUSION CRITERIA

Cancer patients who have received analgesics within 2 hours.

Cancer patients who had damaged skin, inflammation, eczema on feet.

Cancer patients with amputated lower limb.

Cancer patients who have received Chemotherapy.

7.2 METHODS OF COLLECTION OF DATA

Self-administered questionnaire will be used for collection of data

TOOL FOR DATA COLLECTION

Tools for data collection are divided into following categories:

The tool for data collection consisted of three parts

Part – I : Demographic profile

Part – II : Clinical variables

Part – III : Numerical pain rating scale

PART – I

It consisted of demographic profile such as age, sex, religion, education,

marital status, occupation, income, dietary pattern, and type of family.

PART – II

It consisted of clinical variables such as diagnosis, duration of illness, type

of treatment and any other alternative pain relieving measures tried

PART – III

It consisted of a scale ranging 0-10 to assess the pain among cancer patients.

The response ranged from No pain- 0 to Unbearable pain-10

METHOD OF DATA ANALYSIS & INTERPRETATION

The data will be organized, tabulated and analysed by using descriptive and

inferential statistics. The data will be planned to present in the form of tables

and figures.

The data were planned to be analysed in terms of the objectives of the study using

descriptive and inferential statistics.

Descriptive statistics include

1) Frequency and percentage distribution of demographic profile and clinical

variables.

2) Mean and standard deviations of pre assessment and post assessment pain scores.

Inferential statistics include

1) Student independent‘t’ test for comparison of pre assessment and post assessment.

2) One way ANOVA test to find out the association between the post assessments

with the selected demographic variables.

3) Chi square assessment is used to assess the effectiveness of foot massage.

4) The data analysis and interpretations of the results are given in the following

chapter.

TIME AND DURATION OF THE STUDY:

The time and duration of the study will be limited to 6 weeks as per the

guidelines of the university.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER

HUMAN OR ANIMAL?

Yes, since the study is Experimental, study interventions are required.

7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes, the pilot study and the main study will be conducted after the approval

from the research committee of Shridevi College of nursing, Tumkur. Permission will

be obtained from the concerned head of the institutions. The purpose and details of the

study will be explained to the study subjects and an informed consent will be obtained

from them. Assurance will be given to the study subjects on the confidentiality and

anonymity of the data collected from them.

8.0 LIST OF REFERENCES1. Anne. E. Belcher (1992). Cancer Nursing. Mosby Inc. Missouri.

2. Basavanthappa. B.T (2006) . Nursing Research. Bangalore: Jaypee

Brother’s medical publishers.

3. Brunner and suddarth (2008). Text of Medical and Surgical Nursing. 11 th

edition.. New Delhi: Wolters Kluwer India Pvt.Ltd.

4. Carol Taylor, Carol Lillis, Prisalla Lemone (2005). Fundamentals of

Nursing. New Delhi: Wolters Kluwer India Pvt.Ltd.

5. Christine Maskownski (1997). Oncology Nursing; An essential guide for

patient care. Philadelphia: W.B. Saunders company.

6. Christine Mia Skowski, Patrica, Buchsel (1999). Oncology Nursing. 1st

edition. Mosby Inc. Missouri.

7. Edward. A. Shipton (1999). Pain acute and chronic. 2nd edition.

Johannesburg: W. H. Waters and University Press.

8. Jim Cassidt, Donald Bissett, Roy A.J.Spence (2002). Oxford hand book of

Oncology. New Delhi: Oxford University Press.

9. Lewis et al (2007). Text Book of medical and surgical nursing. 8th edition.

Mosby publications.

10. Mahajan (1991). Methods of Biostatistics. New Delhi: Jaypee brother’s

Medical Publishers Pvt Ltd.

11. Buckley J.(2002). Massage and Aroma therapy: Nursing arts and

science. International journal of palliative Nursing, 35(2): 75-80.

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patients. Cancer Nursing.70(2): 179-187.

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pain during last 3 months of cancer patients life. Results of an Italian

follow back survey. Journals of oncology.17;281(11):1030-

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15. Deimling T.Gary, Bowman, F.Karen, Wagner, J.Louis (2007). The

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long term cancer survivors. Cancer Nursing. 54: 367 -369.

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Sep;83(9):677-85.

21. .radiotherapy. http://en.wikipedia.org/wiki/Radiotherapy.

22. http:// www.anmc.org.au

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9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE

11 11.1 NAME AND DESIGNATION OF GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL.

12.2 SIGNATURE