Synopsis Proforma for Registration of Subject for Dissertation
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SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Mr.JITHESH.A.N
I YEAR M .Sc NURSING
MEDICAL SURGICAL NURSING
2010-2012
THE KARNATAKA COLLEGE OF NURSING
#12, KOGILU MAIN ROAD, YELAHANKA,
BANGALORE – 560064
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES 2
BANGALORE, KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Mr.JITHESH.A.N
1st yr Msc.NURSING
1. NAME OF THE CANDIDATE AND THE KARNATAKA COLLEGE OF ADDRESS NURSING #12, KOGILU MAIN ROAD, YELAHANKA, BANGALORE-560064.
THE KARNATAKA COLLEGE OF NURSING NAME OF THE INSTITUTION #12, KOGILU MAIN ROAD, 2. YELAHANKA, BANGALORE-560064.
3. COURSE OF THE STUDY AND I YEAR M. Sc NURSING SUBJECT MEDICAL SURGICAL NURSING
DATE OF ADMISSION TO THE COURSE 4. 15-06-2010
A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON 5. TITLE OF THE STUDY KNOWLEDGE REGARDING ASEPTIC WOUND DRESSING PRACTICES AND CARE OF DIABETC FOOT AMONG STAFF NURSES AT SELECTED HOSPITALS, BANGALORE. 3
6. BRIEF RESUME OF THE INTENDED WORK
6.1INTRODUCTION
“The most important practical lesson that can be given to nurses is to teach them what to observe”
Florence Nightingale
Diabetes mellitus is a group of metabolic disease characterized by increased levels of glucose in the body (hyperglycemia) resulting from defects in insulin secretion, insulin action or both2. In diabetes the cells may stop responding to insulin entirely. Long term effects of hyperglycemia contributes to (coronary artery disease, cerebrovascular accident, peripheral vascular obstructive disease), chronic micro vascular complications (kidney and eye disease) and neuropathic complications
(diseases of the nerve) 1.
In United state an estimated 20.8 million people or 7% of the population has diabetes mellitus. And 41 million more people have prediabetes. The long term complications of diabetes are what make it such a devastating disease. Diabetes is the leading cause of adult blindness, end stage renal disease, and diabetic foot ulcerations, leading to lower limb amputations.1 Between 50 % to 75 % of lower extremity amputations are performed on people with diabetes. More than 50% of amputations are thought to be preventable, provided patients are taught foot care measures and practice them on daily bases.2
Foot complications are the most common cause of hospitalization in the person with diabetes 3. The development of foot ulcers complications is a multifactorial process 4. The diabetic foot covers the spectrum of neurological, arterial and 4 infectious foot problems that occur as a consequence of diabetes5. From 50% to 75% of lower extremity amputations are performed on people with diabetes. More than
50% of these amputations are thought to be preventable, provided patients are taught foot care measures and practice them on a daily basis (ADA, Preventive Foot Care in
People With Diabetes, 2003).6 Foot assessment and foot care instructions are most important when caring for patients who are at high risk for developing foot infections.6The treatment consists of effectively alleviating mechanical pressure from the wound (i.e. prevention of repeated trauma by walking on the ulcer) on the one hand, and using adequate local care on the other hand7. The best treatment however aims at prevention of foot ulcers6. It requires the knowledge of about the path physiological mechanisms of diabetic foot, the screening for feet at risk, and the education of the patient, family and the health care providers8.
Education plays a vital role in prevention of foot ulcers from sepsis. The aim is to increase motivation and skills and knowledge that enhance the nurse in wound caring. Despite being one of the most serious and costly complications of diabetes, foot complications are effectively prevented. The multidisciplinary treatment of foot ulcers, appropriate organizations, close monitoring and education of people with diabetes and health care professionals, it is possible to reduce amputation rates by up to 85% 9. Education regarding proper wound dressing in aseptic method, control of diet, proper wound care in home, regular health check up, and use of proper insulin in time, those reduces the risk wound sepsis and reduces chance of lower extremity amputation.
6.2 NEED FOR THE STUDY 5
“Learning is not attained by chance, it must be sought for with ardor and attended to with diligence.” Abigail Adams
Diabetes is the fourth leading and a serious health problem that lead to cause of death globally and its prevalence is increasing rapidly. The burden is particularly harsh in low or middle income countries, where many children with type
-I diabetes die because they lack access to life saving insulin and where many do not receive the education required to delay and prevent complications1.
According to World Health Organization (2009) the total number of people with diabetes worldwide is 171 million in 2000 and is projected to rise up to 366 million in 203011. International working group on the diabetic foot
(2005) estimated that each year, around 3.8 million adults die from diabetes related causes, i.e. 6 deaths every minute. It is estimated that 250 million people worldwide have diabetes representing roughly 6% of the adult population (20-79 age group). The number is expected to reach 380 million by 2025, representing 7.1% of the adult population10.
According to WHO (2009) The top 10 countries suffering from diabetes are India, China, USA, Indonesia, Japan, Pakistan, Russia, Brazil, Italy and
Bangladesh . Recent studies in China, Canada, USA, and several European countries have shown that feasible lifestyle intervention can prevent the onset of diabetes in people at high risk. Overall direct health care cost of diabetes ranges from 2.5% to
15% annual health care budget of a country. According to Centers for Disease Control and Prevention (CDC - 2009) from 1980 to 2000, the number of Americans with diabetes is more than double. Currently, it is estimated that almost 21 million people 6 in the US are affected by diabetes; by 2030 this figure is expected to exceed 30 million. 2
According to International Diabetic Federation in 2006, "the disease now affects a staggering 246 million people worldwide, with 46% of all those affected in the 40-59 age group. This survey shows nearly 60% of the patients are suffering from diabetic complications. The new data predict that the total number of people living with diabetes will skyrocket to 380 million within twenty years if nothing is done."12
American Podiatric Medical Association 2006 new survey commissioned by the American Podiatric Medical Association (APMA) discovers that problems are particularly challenging among Hispanic-American patients, finding that One-third of
Hispanic Americans without diabetes report foot and leg problems, according the
APMA survey. These lower-extremity problems include numbness, tingling or burning, as well as cramping calves, which are all precursors of diabetes, according to the survey of 600 patients. The APMA says the survey results are in line with statistics from the Centers for Disease Control and Prevention, which estimates that almost half of the 2.5 million Hispanic Americans with diabetes do not know they have the disease. 13
National diabetes statistics (2007) in a survey on prevalence of diagnosed and undiagnosed diabetes in US, in all age group in 2007, showed that total diagnosed patients are 23.6 million people, i.e. 7.1% of total population has diabetes. In this
17.9% people are diagnosed and 5.7% people are undiagnosed. There are approximately 798,000 new cases of diabetes which are diagnosed annually in the
United States. The incidence rate is 1 in 340or 0.29%43. In MMWR Weekly (2008) a 7 report summarized that annual age incidence of diabetes is 5-12.8 per person in US.
The incidence increased 90% from 4.8 per 1,000 in 1995-1997 to 9.1 in 2005-2007. 14
The International Diabetes Federation (IDF) has proclaimed 2005 to be the "Year of the Diabetic Foot." Together with the International Working Group on the Diabetic Foot and related wounds, the IDF has launched a year-long campaign to raise awareness of the diabetic foot worldwide. In this organizations are briefly described, an overview of the aims of the global awareness campaign is given, and the activities to promote World Diabetes Day in 2005 are outlined. Attention is also paid to present and future developments to improve the standards of diabetic wound care worldwide. 12
Dr.Kshitij shankhdhar 2008 conducted a study about diabetes and diabetic wounds in India and stated that diabetic foot is the most complication and that cause increase mortality and morbidity in diabetic patients. Diabetic wound care is one of the ignored aspects of diabetic care in India. Due to social religious and economic compulsions many people walk bare foot. This lead to inappropriate usage of foot wear and late presentation of foot lesion. India has 42 million people with diabetes and related complications; put it first on the list of the 10 nations most affected by this disease. The study on 18,000 people in India reveals that 70% of undiagnosed diabetes mellitus, which is higher than expected. In this 25% of those with diabetes may develop diabetes ulcer. 15
Infectious Diseases Society of America (IDSA) In 2003, the
International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific for these infections.
The following year, the Infectious Diseases Society of America (IDSA) published 8
their Diabetic Foot Infection Guidelines. In this review some of the critical points
from the Executive Summary of the IDSA document Diabetic foot infections are a
common and often serious problem, accounting for a greater number of hospital bed
days than any other complication of diabetes. The patients who admitted in hospital
with diabetes need more care from infections, use of antibiotics, OHA’s, and proper
wound dressing and foot care. 16,17,18,19
Dr. Vijay Viswanathan (2006) conducted a study on diabetic foot in
India and stated that diabetes is common in Indians of Asian subcontinent. India alone
has 35 million diabetic patients and India will have the largest number of diabetic
patients by the year 2025. 10 According to International Diabetic Federation (2005)
India alone counts over 35 million people with diabetes. Estimated figures for 2025
suggest that this will reach 73.5 million as a consequence of longer life expectancy,
sedentary lifestyle and changing dietary patterns10.
Diabetic foot problems are among the most serious complications of
diabetes. The rising prevalence of diabetes all over the world has brought with it an
increase in lower limb amputations performed as a result of the disease14.
Epidemiological reports indicate that over 1 million amputations are performed in
each year. This amounts to a leg being lost to a diabetic patient somewhere in the
world every 30 seconds20.
6.2 REVIEW OF LITERATURE
The review of literature is an integral component of any study of research project. It enhances the depth of knowledge and provides a clear understanding regarding a topic. It refers to an extensive, exhaustive and systematic examination of 9 publications relevant to the research project11. This chapter presents a review of selected literature relevant to the study which is discussed under the following headings:
1. Literature related to importance of diabetic wound dressing and care practices among
nurses.
2. Literature related to assessment of knowledge of aseptic dressing practices and care of
diabetic wound in diabetic patients among staff nurse.
3. Literature related to effectiveness of self instructional module on dressing practices
and care of diabetic wound in diabetic patients among staff nurse.
1. Literature related to importance of diabetic wound dressing and care practices
among staff nurses
Bale S, Baker N 2001 Few studies have investigated the use of dressings on
patients with diabetic foot ulceration. This paper reports the results of a non-
comparative, two-centre study investigating the performance characteristics of
SeaSorb dressing in patients with this condition. The study was conducted on 41
patients. The relative ulcer area showed a significant decrease from 100% to 33%. A
total of 12 adverse events were reported: seven mild to moderate and five severe.
None were directly attributed to the study dressing. 21
Lalau JD, Bresson R 2002 the study aimed at comparing the efficacy and
tolerance of an alginate wound dressing with Vaseline gauze dressing in the treatment
of diabetic foot lesions. Seventy-seven patients were enrolled. The study concluded
that As compared with Vaseline gauze, calcium alginate appears to be more
appropriate for topical treatment of diabetic foot lesions in terms of both healing and
tolerance. 22 10
Hayter M, Chang CJ 2008 This shows a systematic review with the objective of determining the importance and effectiveness of aseptic silver-releasing dressing in the management of infected chronic diabetic wounds. The review included randomised or non-randomised control trials. Of the over 1957 potentially releasing studies examined. This review strengthens the case for the use of silver dressings when managing infected chronic wounds. 23
Russell L, Crespi A 2006 To compare the importance of the sustained silver- releasing foam dressing with local best practice (LBP) on delayed healing diabetic ulcers using a real-life setting. A total of 619 patients with ulcers of varying etiologies were treated for four weeks with either the silver foam dressing or LBP. This study shows that the silver foam dressing supports faster healing of delayed healing wounds.
24
Kirsner RS, Warriner R 2010 To assess the clinical use of advanced biological therapies in treating diabetic foot ulcers in practice and the effect of these therapies on time to healing. This was a retrospective cohort study. 2517 patients with diabetic neuropathic foot ulcers. The study reveals that there were much more improvement
Advanced biological therapies within 1 month, and improved healing of refractory diabetic foot ulcers. Differences on outcomes among advanced biological therapies were noted. 25
Warren S. Joseph 2010 a large randomized trial looking at the use of silver dressings in venous leg ulcerations (LU) and diabetic foot. This study of 213 recruited patients not only looked at wound healing differences between silver-containing dressings and non-silver, low adherence dressings in the treatment of diabetic wound.7
The effectiveness of silver dressings as a class, the VULCAN study found no 11 significant differences between dressings in the number of ulcers healed at 12 weeks
(59.6 percent in silver dressings, 56.7 percent in non-sliver dressings) and no differences in median time to healing.26
2. Literature related to assessment of knowledge on dressing practices and care of diabetic wound in diabetic patients among staff nurse.
Smide B 2009 A comparative study examining diabetic patients in Tanzania and Sweden with a quantitative approach. The aim of the current study was to present the outcome of clinical nurse performed foot examinations in comparsion with
Tanzanians and Swedish patients. 145 diabetic patients in each country were examined, matched in gender and age. This study concluded that Nurse performed foot examinations showed that the Tanzanian diabetic patients in this study had poorer foot status than the Swedish study sample. 27
Gulam-Abbas Z 2002 A prospective cohort study of newly hospitalized, adult diabetes patients with foot ulcers was conducted. 627 diabetes patients evaluated during the study period, 92 (15%) had diabetic foot ulcers. Of these 92 patients, 30
(33%) were selected for surgery (minor and major amputations). This study reveals that Diabetic foot ulcers are associated with significant morbidity and mortality in
Tanzania. Education of patients should underscore the importance of foot care and consulting a doctor during the early stages of foot ulcer disease. 28
Oyibo SO, Jude EB 2001 The aim of this study was to determine the effects of ulcer size, site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. 194 (77% males) with a mean age of 50-60 were included in the study. The majority of ulcers were neuropathic (67.0%) and present on the forefoot.
This study concluded that Ulcer area, a measure of ulcer size, predicts the outcome of 12 foot ulcers. Its inclusion into a diabetic wound classification system will make that system a better predictor of outcome. 29
Gul A, Basit A 2006 conducted a study to compare the effectiveness of diabetic ulcers in directing appropriate therapy and possibly predicting outcomes. A total of 383 patients with foot ulcer were seen. Out of the 200 subjects, 65% were males and 35% were females Forty five percent of the subjects had neuropathic ulcers. the study has revealed that grading and staging of diabetic foot ulcer affects and predicts the outcome. Amputation rates increase with increase in grade. This helps further on assessing the severity of wound at the time of presentation and shows better association with the outcome. 30
Jeffcoate WJ 2006 conducted a study to compare different outcome measures in the audit of management of diabetic wounds. Data collected in 449 patients, 352 (78.4%) ulcers were superficial and 134 of these (38.1% of 352) were neither ischemic nor infected. This study means ulcer-related outcomes may underestimate the true morbidity and mortality associated with diabetic foot disease. It suggested that when attempts are made to compare the effectiveness of management in different centers, greater emphasis should be placed on patient-related outcome measures. 31
3.Literature related to effectiveness of self instructional module on dressing practices and care of wound in diabetic patients among staff nurse.
Nonino EA, Anselmi ML, Dalmas JC 2008 conducted a observational and sectional study analyzed the quality of the wound dressing procedure performed on hospitalized patients at a medical surgical unit of a University Hospital, based on their classification according to the degree of care dependency and activity performance phases. Using a check list, 168 wound dressings were observed between October and 13
December 2005. Procedure quality was analyzed based on the Positivity Index (IP).
Rigorous execution of procedures allows for risk decrease and assures beneficial results for patients, conferring quality to nursing actions. 32
Bree-Williams FJ, Waterman H. 1996 The purpose of this study was to establish if nurses' actions when carrying out 'aseptic technique' using the 'gloves technique' are simple and based on up-to-date knowledge and do not incur unnecessary wastage. A sample of convenience was used involving 21 trained nurses.
Observation and formal interviews were used to collect quantitative and qualitative data. Results showed that not all nurses in the sample applied a 'simple aseptic technique'. The rationale for the practice of aseptic technique was not always research based, though other aspects of wound management were derived from research findings. The study highlighted other areas of aseptic technique which require investigations. 33
Wise LC, Hoffman J 1997 This prospective, descriptive study surveyed staff nurses regarding glove use in diabetic wound dressing. The application of sterile and clean procedure to the practice of wound care nursing was examined. A self-report wound care survey instrument was developed by Nursing Consortium for Research and Practice members. The questionnaire comprised 31 questions and required approximately 10 minutes to complete. Differences were found between acute care and home health nurses. These included health care setting, degree of professional education, and nurses' experiential background. Instead, it may be necessary for nurses to "unlearn" lessons from basic nursing education before they can adapt to new practices and clinical policies. 34 14
Akyol AD 2007 A self instructional study was conducted on nurses University of Ege Faculty of Medicine Application and Investigation Hospital at Internal
Medicine Clinics. This study aims to identify nurses' practices and opinions of hand washing during diabetic wound care. A questionnaire survey was used for this study.
A total of 129 clinical nurses was examined. The study revealed that nurses have a poor level of knowledge concerning quality of hand washing. These conclude that to improve hand hygiene and quality of hand washing compliance, additional factors must be considered. These factors include improving healthcare workers--especially nurses'--skin conditions, hand hygiene techniques and disinfections substantially. 35
Nagoba BS et al. April 23, 2010: This is a retrospective case series from India that collected data from 1998 into 2009. A self instructional study about wound dressing was done. They looked at the application of a 3% citric acid gel preparation onto 115 diabetic ulcerations. Culturing was collected from wound site. They found that in moderate ulcerations they had 94%+ healing. They concluded that citric acid was safe and maybe even promoted granulation tissue while killing the bacteria found on the wounds. 36
Caron-Mazet J, Roth B, Guillaume JC 2007 survey to assess the prevalence of various therapeutic approaches for chronic diabetic wounds in 14 primary care and rehabilitation units and long-term care units. 96 of the 1 163 patients hospitalized at the time of our survey met the inclusion criteria. Wounds were generally cleansed using soap and physiological saline, No topical antibiotics were prescribed. anecdotal use of antiseptic solutions and nutrition management plans was done. This survey showed that doctors and nursing staff are extremely keen on the 15 idea of specific training and practical advice concerning chronic diabetic wound management.37
Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA. 2006 this study to assess the effectiveness of wound dressings for the treatment of diabetes wounds and venous leg ulcers. 42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression.38
Brem H, Tomic-Canic M, Tarnovskaya A, Ehrlich HP 2003 the elderly population has a higher incidence of chronic wounds: diabetic foot ulcers, pressure ulcers, and venous stasis ulcers. 40 consecutive elderly patients (65-102 years old) with chronic wounds were analyzed. This suggests that elderly patients with diabetic foot ulcers, pressure ulcers, and venous stasis ulcers close their wounds at a similar as youngers. early intervention and comprehensive treatment includes safe topical therapies, if all elderly patients with chronic wounds are provided early treatment, morbidities (e.g., amputation, sepsis, pain) and associated costs will decrease.39
6.3 A) PROBLEM STATEMENT
A study to assess the effectiveness of self instructional module on knowledge regarding diabetic wound dressing and wound care practices among staff nurse at selected hospitals, Bangalore. 16
6.3 B) OBJECTIVES
1. To assess the pre-interventional knowledge regarding diabetic wound dressing and
wound care.
2. To determine the effectiveness of self instructional module regarding diabetic wound
dressing and wound care.
3. To assess the post-interventional knowledge regarding the aseptic methods of diabetic
wound dressing and wound care.
4. To find out the association between selected staff nurses from the wards with
knowledge regarding diabetic wound dressing and care of diabetic wound among
staff nurse
6.3 C) OPERATIONAL DEFINITION
1) Assess
It refers to the evaluation of desired or intended results of the study.
2) Effectiveness
It refers to the successfulness in producing desired or intended result
that is brought by administration of self instructional module.
3) Self instructional module
It refers to the learning material prepared in Kannada and English
language, by the researcher to provide information regarding diabetic dressing and
wound care by the staff nurse.
4) Knowledge 17
It refers to the level of understanding and awareness of staff nurse on diabetic wound dressing practices assessed by self administered questionnaire.
5) Diabetic wound or diabetic ulcer.
It refers to an ulcer in the upper or lower extremities due to any injury or infection, secondary to diabetes mellitus, or due to peripheral neuropathy.
6.3 D) HYPOTHESES
H1.There is a significant difference between pre-test and post- test level of knowledge of the staff nurses after administration of self instructional module on effectiveness of aseptic dressing in diabetic foot ulcers and wound care.
6.3. E) ASSUMPTION
1. The staff nurses may have some knowledge regarding diabetic wound dressing
and wound care.
2. Diabetic wound dressing and care practices among staff nurses can be
measured by using structured questionnaire.
3. Diabetic wound dressing and care practices among staff nurses can be
improved by administering self instructional module.
4. Effectiveness of self instructional module can be assessed by pre and post
knowledge score among nurses.
6.3 F) LIMITATIONS OF THE STUDY
1. The sample size is limited to 60. 18
2. The study is limited to staff nurses in selected hospital from Bangalore.
7 MATERIALS AND METHODS
7.1 Sources of data:
The data will be collected from staff nurses working in selected departments in selected hospitals at Bangalore.
7 .2 Methods of data collection
i) Research design:
Non experimental.
ii) Research approach:
Evaluative research approach
iii) Research variables:
a) Dependent variable: Knowledge of staff nurses on diabetic wound
dressing practices.
b) Independent variable: Self instructional module on knowledge of
diabetic wound dressing practices in diabetic foot and wound care.
iv) Setting:
The study will be conducted in selected departments of selected
hospitals at Bangalore.
v) Population: 19
The accessible population of the study includes the staff nurses
who are working in selected departments in selected hospitals at Bangalore
vi) Sample:
The staff nurses who fulfill the inclusion criteria will be
considered as samples. The sample size will be 6 for the pilot study and 60 for
the main study.
vii) Criteria for sample selection:
a) Inclusion criteria:
1) Staff nurses who are working in the selected hospital.
2) Staff nurses who are willing to participate in the study.
3) Staff nurses who are able to read and write Kannada/
English.
b) Exclusion criteria:
1) Staff nurses who are not willing to participate in the study.
viii) Sampling technique:
Non probability convenience sampling technique.
ix) Tool for data collection:
The tool consists of following sections
The structured questionnaire scheduled which is constructed in English and Kannada language.
Section 1: Demographic proforma 20
Demographic proforma includes number of staff nurses participated in this study, assess knowledge obtained about diabetic foot dressing practices and wound care.
Section 2: structured questionnaire
This consists of questionnaire to assess the knowledge of the staff nurses regarding diabetic wound dressing practices. x) Method of data collection:
After obtaining permission from concerned authority and informed consent from samples, the researcher will collect data from samples on the basis of inclusion criteria.
Phase 1: Pretest will be conducted to assess the knowledge of the staff nurses on diabetic wound dressing practices using self administered questionnaire. Duration will be 2 days.
Phase 2: Self instructional module on diabetic ulcers dressing methods will be distributed to the staff nurses after phase 1.
Phase 3: After 3 days post test will be administered to assess the level of knowledge on diabetic wound dressing practices to the same subjects with the help of same questionnaire
Duration of the study: 8-10 days. xi) Plan for data analysis
The data will be analyzed by means of descriptive and inferential statistics 21
a) Descriptive statistics –mean, median, mode, standard deviation, percentage
distribution will be used to assess the knowledge of the staff nurses on
dressing diabetic foot ulcers in aseptic method and wound caring.
b) Inferential statistics –chi square test will be used to associate the knowledge
of staff nurses working in various departments.
xii) Projected outcome.
After the pretest the investigator administers self instructional module to the staff nurses regarding diabetic foot dressing practices and it will help them to initiate a positive step in diabetic wound care
7.2 Does the study require any investigation or intervention for the staff nurses on other human being / animals?
Yes
7.3 Has ethical clearance been obtained from the concerned authority to conduct the study?
Yes.
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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 : 28
11.4 Signature :
11.5 Head of the department :
11.6 Signature :
12. Remarks of the Principal :
12.1 Signature : 29