Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka s1
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PERFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1. NAME OF THE Ms. Jessy Varghese
CANDIDATE AND M. Sc. Nursing (Medical Surgical nursing)
ADDRESS Anuradha College of Nursing
Bangalore
2. NAME OF THE Anuradha College of Nursing Bangalore INSTITUTION
3. COURSE OF STUDY 1st Year M. Sc. Nursing
AND SUBJECT Medical Surgical Nursing
4. DATE OF ADMISSION 01-05-2012
TO COURSE
A STUDY TO ASSESS THE 5. TITLE OF THE TOPIC EFFECTIVENESS OF FOOT REFLEXOLOGY ON PERFORMANCE OF DEEP BREATHING AND COUGHING EXERCISES IN PATIENTS AFTER STERNOTOMY IN SELECTED HOSPITALS IN BANGALORE. 6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION.
Pain is an unpleasant and highly personal experience that may be impercible to others, while consuming all parts of the person’s life. Pain presents both physiologic and psychologic dangers to health and recovery. Post-operative pain is caused by the interaction of number of physiologic and psychologic factors. Despite the availability of analgesic drugs and pain relieving techniques, pain remains a common problem and a significant fear for the patient in post operative period 1
Reflex massage is used as a useful treatment method in China, Egypt and India for the hundreds of years. Reflexology, or zone therapy, is an alternative medicine involving the physical act of applying pressure to the feet, hands, or ears with specific thumb, finger, and hand techniques without the use of oil or lotion. Dr Fitz Jerald introduced some parts of body such as ear, nose and throat as treatment points for the first time in early 1900 in south of America. According to this, the energy is following through vertical pathways all over the body from foot to head. So, pressure on a reflex point can effect on the whole body such as glands, bones and muscles. One of the proposed theories is that there are canals in the body, which the life power or the vital energy follows through them from feet to whole organs of the body and any barrier in this flow would finally cause disease4.
In recent years, use of treatment methods of the alternative medicine such as massage is increased in medical units.5The soft tissue touching used in the treatment massage, would cause pain decrease and ease increase in patients and would consequently increase patients’ adjustment power against occurred conditions 6
Nowadays, the relationship between heart disease and mental situation is proved. Because of this, use of the alternative medicine for these people causes health promotion and comfort increase that is very effective on treatment procedure7. Coronary diseases are the most common heart disease which in spite of recent effective medical methods of treatment, many patients may require sternotomy for vessel graft. Coronary artery bypass graft (CABG) is an effective method for decrease or removal of cardiac angina.7 Chest pain in sternum is one of the most common complications after CABG. The pain after sternotomy is probably because of the nervous fibers’ cut in scar and is described as a vague pain around surgery area and in the cut area. Pain can last for 3 months as a chronic pain that starts in first hours after surgery and would get better usually with narcotic medications until 48 hours after the surgery. The pain causes activation of the nervous system and then the cardiovascular system and the created cycle would increase cardiovascular performance. The heart rate and the blood pressure increase, increases myocardium demand for oxygen and this would hinder the recovery procedure after surgery.
The pain also affects the activity rate of patients and increases the surgery complications. Because of this, the effective pain control would lead to decrease of cardio-pulmonary complications after open-heart surgery. Massage is one of the old techniques used in pain treatment and has been considered in recent studies very much. Anderson studied massage effect on shoulder and neck pain in patients after CABG in year 2007. Findings of this study demonstrated the massage positive effect on pain relief of patients.7Gunnarsdottir has recommended foot massage on pain relief of CABG patients. Reflex massage is a simple and none invasive method that can be taken into account as a part of nursing care in intensive units.7 Because of this, an interventional study was performed with the goal of evaluating the effect of foot reflex massage on chest pain decrease in CABG patients after surgery7
6.2 NEED FOR THE STUDY
The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Post operative pain can be defined as pain resulted from surgical intervention. Pain is generally protective, it warns of tissue damage and prompt treatment, but post operatively it can hold up recovery. Factors that affect post operative pain consist of the previous experience, surgical intervention, intra operative pain management, site and size of incision and extent of surgical trauma.9
The basic pain mechanism consists of mainly four processes such as transduction, transmission, perception and modulation. Surgical tissue damage causes release of substances such as bradykinin, arachidonic acid, histamine, 5-hydroxytriptamine, substance P and prostaglandins. These chemicals stimulate peripheral pain receptors which transmit the pain impulses. This pain impulse is transmitted to spinal cord through neuronal fibers. From there sensory information is carried through the spinothalamic tract and spinonueclear tract to the thalamus and the reticular activating system. Neurons from the thalamus project to cerebral cortex for the conscious perception of pain. (Krik.R.M, W.T. Ribbans, 2004).When pain stimulus reaches the brain stem and thalamus naturally it stimulate the release of endorphins and enkephalins,which may inhibit pain transmission at spinal cord.10
Reflexology is a bodywork modality in the field of Complementary and Alternative Medicine (CAM). Reflexology is the act of applying pressure on specific areas of hands and feet that correspond to particular organs and glands of the body using specific thumb, finger and hand techniques. Reflexology therapies are classified in to three types: ear reflexology, hand reflexology and foot reflexology. The basic concept of foot reflexology promotes homeostasis. Foot reflexology improves blood circulation, lymphatic circulation and also motivates relaxation; good sleep and wound healing.11 6.3 REVIEW OF LITERATURE
Review of literature is a critical summary of research on a topic of interest generally prepared to put a research problem in paper content to identify gaps and weakness on previous studies to justify a new investigation. The review of literature for the present study has been divided into the following sections Studies on the effect of foot reflex massage on sternotomy pain Studies on the effect of foot reflex massage on pain
Studies on the effect of foot reflex massage on sternotomy pain
A study was performed to investigate the effect of foot reflex massage on sternotomy pain of patients after coronary artery bypass graft surgery. In a quasi-experimental study, 90 patients were randomly divided into three groups of case, control and placebo. The reflexology group received a 10-minute right foot massage in desired location twice a day with 6 hours intervals for 2 consecutive days. The placebo group undertook a 10-minute left foot massage and the control group received no intervention. Only at mentioned times, the amount of pain was measured by McGill visual scale. The mean of pain intensity before and after intervention had significant difference in three groups (p<0.001). Average of pain intensity in the case group was 6.4(±2.1) before intervention and 3.4(±5.1) after intervention. The mean of pain intensity in control group before and after intervention was respectively 5.1(±1.7) and 5(±1.9). Independent T-test showed a significant reduction in intensity of post- operative pain between case and control groups (p<0.001). Foot reflex massage appears to be a useful method for reducing sternotomy pain in patients after coronary artery bypass graft surgery.14
Nationwide research study undertaken in Denmark reported that, reflexology treatment has a positive effect on patients suffering from migraine and tension headaches. The study was done at the Department of Social Pharmacy, The Royal Danish School of Pharmacy with the help of five reflexology associations. 220 patients were participated in the study. Reflexology was performed by 78 fully trained reflexologist. Among the patients who took part in the study, ninety percent reported that they had already started to take the prescribed medication one month before the study and, out of them, 36 percent had experienced ill effects from the medicines. Eighty one percent of the prescribed medicine in the acetylsalicylic acid and paracetamol group was taken at least twice a week and 72% of the stronger medicines were taken at least once a fortnight which point out that the greater part of the patients were suffering from moderate to severe symptoms. After three months of reflexology treatments, eighty one percent of patients confirmed that reflexology helped them in reducing their symptoms. Nineteen percent of the patients re-ported that they had been able to completely stop the medications they had been taking before the study.15
A study was carried out to examine the effect of foot reflexology on sternotomy pain of patients undergone CABG at Iran University of Medical Sciences (2007). This was a quasi-experimental study, 90 patients were randomly divided into three groups of case, control and placebo. The reflexology group received a 10-minute right foot massage in desired location, two times a day with 6 hours interval for 2 successive days. The placebo group received a 10-minute left foot massage and the control group received no intervention. Pain was assessed using visual analogue scale. Outcome showed that the mean of pain intensity before and after intervention in three groups had a significant difference. In the case group average pain intensity before the intervention was 6.4(±2.1) and after the intervention was 3.4(±5.1). In control group the mean of pain intensity before and after intervention was respectively 5.1(±1.7) and 5(±1.9). Independent t-test showed a significant reduction in intensity of postoperative pain between case and control groups.16
A randomised control trial was done to assess the effect of foot reflexology on pain and physiological parameters after caesarean section in patients referring to Alzahra educational center in Iran. Sixty two women were randomly divided into two groups of case and control. The reflexology group received a 30-minute foot massage in two sessions, with 24-hours interval. Data gathering tool included a demographic form, step-visual analogue scale, pain score and physiological parameters form, and chronometer. Result showed there was no demographical difference between two groups and they were matched completely. In case group, severity of pain after first stage of foot reflexology was lower than control group. The severity of pain after second stage was significantly reduced in case group in comparison with control group. After first stage of foot reflexology in case group, systolic blood pressure decreased and after second stage it increased, but average of pain intensity showed no significant difference assumed with control group. The mean pulse rate, after both first and second stage, decreased significantly, but there was no significant difference between groups. Diastolic blood pressure and respiratory rate did not vary between case and control groups. Study concluded that foot reflexology appears to be a useful method for reducing pain in post operative patients.17
Studies on the effect of foot reflex massage on pain
Foot reflexology in post operative pain reduction: A study was conducted at AIIMS, New Delhi (2002–2004) to find out the efficiency of reflexology in postoperative pain management. Sixty patients were divided randomly into Reflexology group (foot reflexology and required quantity of standard drugs) and Control group (standard quantity of standard drugs alone).Standard drugs included are NSAID (Diclofenac) and Opioids (Pethidine and Fentanyl).Pain score was measured by using a visual analog scale of 0 - 10. Pain was measured at the time scale of 0, 2, 6, 24 hours. 0 hours is the time which patient was shifted to recovery room. The results showed a considerable decrease in pain scores and decrease in the requirement and quantity of drugs among reflexology group compared to control group.18
A study was at Division of Science and Design, University of Canberra, Australia on the use of foot massage as a nursing intervention in patients admitted with cancer. 87 patients were participated in the study and each one received a 5-minute reflexology foot massage per foot. The study reported that the reflexology has a significant and immediate effect on the pain, nausea, and relaxation, when it was measured with a visual analog scale.19
A study was conducted at the Hospital of Beijing College of Languages to assess the effect of reflexology treatment on acute lower back pain. Twenty patients between the ages of 35 and 55, suffering from lower back strain was participated in the study. Ten reflexology therapies were delivered to each patient. All patients reported that the treatment had effectively reduced their pain. 5 of them obtained complete relief after one treatment, 10 patients obtained relief after 3 to 4 treatments and 5 patients got complete relief only after 5 to 7 treatments. No analgesics or other medications were used all over the course of treatments.20 A study was conducted to assess the effectiveness of foot reflexology on pain and anxiety in patients admitted with breast and lung cancer. It was a quasi-experimental, cross over study done at medical and oncology units of a 314-bed hospital in the South-Eastern United States. Twenty-three in-patients with breast or lung cancer were taken for the study. The bulk of the samples were receiving regularly scheduled opioids and adjuvant medications. Procedures included a foot reflexology to both feet for 30 minutes during intervention condition and with at least a two-day break during control condition for each patient. No changes were made in patient’s usual schedule or medications. Following the foot reflexology intervention, patients with breast and lung cancer experienced a significant reduction in anxiety and pain.21
A study was conducted to assess the effectiveness of foot reflexology as a pain killer in China (1998). Reflexology was done to 60 individuals between ages 1 to 73 to reduce the pain resulted from toothache, headache, sore throat, stiff neck, shoulder pain,old wound, breast pain, chest & rib pain, dysmenorrhoea, abdominal pain , wrist and leg pain and joint pain in limbs. Reflexology sessions lasted for 20 minutes to 40 minutes. Following one session 18 of the 60 were healed. 11 were nurse back to health following 2 or 3 sessions, 22 were effectively treated after 2 or 3 sessions. Reflexology was not effective for 9 cases after 1 to 3 sessions.22
A study was conducted to look into the efficacy of foot reflex therapy as adjuvant treatment modality in reducing pain and anxiety in postsurgical patients with gastric and hepatocellular cancer at Taiwan (2005). It was a randomized controlled trial. Sixty-one patients who had undergone surgery for gastric or hepatocellular carcinoma were randomly assigned to intervention (n = 30) or control (n = 31) group. Patients in the experimental group received 20 minutes of foot reflexotherapy in addition to the usual pain management during 2nd, 3rd and 4th postoperative days. Patients in the control group got usual pain management only. Outcome was measured using short- form McGill Pain Questionnaire, VAS, summary of the pain medications taken, and the Hospital Anxiety and Depression Scale. Intervention group reported less pain and anxiety over time when compared with the control group. The study also revealed that the patients in the experimental group received significantly less pain medications than the control group.23 A study was conducted to compare effects of symptom management with reflexology on pain and frequency of pain medication taken in old age patient with prostatectomy at Suratthanee Hospital, Thailand (2005). Quasi-experimental, pretest –post test design was used with a control groups. 40 elderly patients were selected and allocated to experimental and control groups. The instrument used for the study consisted of four sessions; Symptom experienced assessment, Knowledge providing, Reflexology and evaluation phases. Data were analyzed by using descriptive statistics and t-test. The study reported that the posttest mean score on pain of an experimental group was significantly lower than of the pretest. The post test mean score of pain of an experimental group was significantly lower than of a control group. The posttest mean score of frequency pain medication taking of an experimental group was significantly lower than of a control group.24
A study was conducted to find out the effectiveness of foot reflexology on pain level, vital signs and satisfaction in patients with abdominal surgery by a post graduate student of Mahidol University, Taiwan (2003). It was a quasi experimental research with simple cross over design. Thirty patients were randomly selected to control group and experimental group. Control group received 30 minutes of supportive education and experimental group received 30 minutes of foot reflexology. Pain assessment and vital signs were recorded pre, immediately after therapy and at 15 minutes and 45 minutes interval. The results showed that patient received foot reflexology had marked reduction in pain compared to those received supportive education. It also reported a marked effect in vital signs.25 6.4 STATEMENT OF THE PROBLEM
” A study to assess the effectiveness of foot reflexology on performance of deep breathing and coughing exercises in patients after sternotomy in selected hospitals in
Bangalore”
6.5 OBJECTIVES OF THE STUDY
To determine the pre-test level of post operative pain among sternotomy patients in control and experimental group.
To evaluate the effectiveness of foot reflexology on level of postoperative pain among sternotomy patients.
To find the association of level of post operative pain with selected demographic and clinical variables among experimental group
6.6 OPERATIONAL DEFINITIONS
Effectiveness: Refers to the extent to which the foot reflexology will achieve the desired results in reducing the post operative pain.
Foot reflexology: Refers to the therapeutic method of applying pressure to the specific area of the feet, the reflex points to relieve the pain.
Post-operative pain: Refers to the pain following sternotomy
sternotomy; incision of the sternum as an approach for a thoracotomy. The incision may be median, through the midline, or transverse, most commonly as an extension of an intercostal thoracotomy incision, across the sternum and up the other side.
6.7 HYPOTHESIS: H1: There will be significant statistical difference in the post test level of post operative pain among experimental group and control group
H2:There will be significant statistical difference between the pre-test and post test level of post operative pain in both experimental.
H3: There will be significant association between pre test pain level and selected demographic variables.
6.8 ASSUMPTIONS OF THE STUDY:
Sternotomy patients may experience post operative pain.
Foot reflexology may reduce post-operative pain among sternotomy patients. Effectiveness of foot reflexology may have some association with demographic variables.
6.9 DELIMITATIONS:
The study is delimited only to pain level of strnotomy patients
The study is conducted only on patients who underwent sternotomy procedure. 7 MATERIALS AND METHODS:
7.1 RESEARCH APPROACH:
Research approach used in this study is the evaluative approach
7.2 RESEARCH DESIGN:
The research design adopted for the present study is True experimental time series design.
7.3 SETTING:
The study will be conducted at selected hospital in Bangalore.
7.4 POPULATION:
Population consists of all patients who underwent sternotomy procedure.
7.5 SAMPLE:
Sample selected for the present study is sternotomy patients who are residing at selected hospitals in Bangalore.
7.6 SAMPLE SIZE:
The proposed sample size for the present study is 60
7.7 SAMPLING TECHNIQUE:
The sampling technique adopted for the study is convenient sampling. 7.2.1 SAMPLING CRITERIA:
Inclusion Criteria:
1. Adult patients who underwent sternotomy procedure.
2. Patients who are interested to participate in the study.
3. Patients who are able to read and write Kannada or English
Exclusion Criteria:
1. Patients who are working at health care sector particularly in reflexology.
2. Patients who had previously exposed to similar experiment.
3. Sternotomy patients with severe post operative complications or psychiatric disorders.
7.9 VARIABLES:
Dependent variable:
Pain level of strnotomy patients after foot reflexology intervention
Independent variable:
Information booklet regarding effective contraceptive measures
Extraneous variable
Age, Education, Occupation, Marital status, Economic status, occupation clinical variables of sample such as previous history of caesarean section, previous history of hospitalization, number of deliveries, pain relief methods other than medication, number of hours post operatively
7.10 TOOLS FOR DATA COLLECTION:
Tool 1: Socio demographic data prepared by the investigator.
Tool 2: Numerical rating scale to assess the level of pain, where the score will be interpreted in terms of no pain, mild pain, moderate pain, severe pain and worst pain.
7.11 METHOD OF DATA COLLECTION:
Data will be collected by dividing the patients into two groups, namely experimental group and control group by simple random sampling. Pre-test level of post operative pain will be assessed using the numerical rating scale among the samples who meet the inclusion criteria. The experimental group will then be given foot reflexology on the following day, after which the level of pain will be measured using the numerical rating scale and this will be repeated for five days. While the control group’s pain will be assessed using the numerical rating scale for five days without giving foot reflexology. The data collection period will be for one month.
7.12 METHOD OF DATA ANALYSIS:
The collected data will be analyzed by using the appropriate descriptive and inferential statistics method
Effectiveness of foot reflexology will be tested by using One - way ANOVA F-test.
Chi-square test will be used to find the association between level of post operative pain with selected demographic and clinical variables. `p’ value <0.05 is considered as significant. Analyzed data will be presented in the form of tables, graphs and figures.
7.13 DURATION OF DATA COLLECTION
Duration of data collection will be 4 weeks.
7.14.1 PROJECTED OUTCOME:
The study helps the investigator to attain an idea about the effectiveness of foot reflexology.
The study will help identify the factors affecting the effectiveness of foot reflexology in reducing the post operative sternotomy pain.
7.15 Does the study require any investigation or intervention to be conducted
on patients or other humans or animals? If so, please describe briefly.
Yes, this study requires an intervention (foot reflexology) to be conducted on patients.
7.16 Has ethical clearance been obtained from your institution?
Yes. Ethical clearance will be obtained from the institution for conducting the study. 8. LIST OF REFERENCES:
1. Berman A, Synder SJ, Kozier B, Erbs G. Kozier and Erbs fundamentals of nursing: concepts, process, & practice. 8th ed. New York: Pearson education;2009 2. Raso J. Alternative healthcare: A comprehensive guide. Toronto: Canadian Public Health Association; 1994. 3. Eunice D. Ingham and the development of foot reflex massage in the U.S. London: Routledg; 1989. 4. Cowan T. The reflexology handbook: A complete guide.London: Piatkus; 1998 5. Carol C, Hayes J. Physiologic and psychodynamic response to the administration of therapeutic touch in critical care. Intensive Crit Care Nurs. 1999;15:363-83. 6. Hill C. Is massage beneficial to critically ill patient in intensive care units? Intensive Crit Care Nurs. 1999;9:116-21. 7. Anderson PG, Cutshall SM. Massage therapy: A comfort intervention for cardiac surgery patients. Clin Nurs Spec. 2007;21(3):161-5. 8. Brunner LSH, Suddarth DS. Text book of medical surgical nursing: Cardio vascular. Givari D, Kaffashi J, translators. 2nd ed. Tehran: Boshra; 2000. [Persian] 9. Kunz, Kevin; Kunz, Barbara (1993). The Complete Guide to Foot Reflexology. Reflexology Research Project.
10. Ernst E (2009). "Is reflexology an effective intervention? A systematic review of randomised controlled trials". Med J Aust191 (5): 263–6. PMID 19740047.
11. Norman, Laura; Thomas Cowan (1989). The Reflexology Handbook, A Complete Guide. Piatkus. pp. 22, 23. ISBN 0-86188-912-6 0-86188-912-6 0- 86188-912-6.
12. http://www.ukessays.com/essays/nursing/literature-review-of-postoperative- pain-and-foot-reflexology-nursing-essay.php#ixzz2Hx38RxUF
13. CNHC Wishes to Thank Simon Perry,http://adventuresinnonsense.blogspot.com, Friday, 27 November 2009 14. Sadeghi Shermeh M.1 MSc, Bozorgzad P, MSc, Ghafourian A. R.2 MD, Ebadi A.1 PhD, Razmjoei N.3 MSc, Afzali M.4 MSc, Azizi A.5 MSc, Effect of foot reflex massage on sternotomy pain after coronary artery bypass graft surgery, Faculty of Nursing, Iran University of Medical Sciences, Tehran, Iran, Iranian Journal of Critical Care Nursing Summer 2009, Volume 2, Issue 2; 51-54, http://www.google.co.in/url? sa=t&rct=j&q=foot+reflexology+on+sternotomy&source=web&cd=1&ved=0CC 4QFjAA&url=http%3A%2F%2Fwww.inhc.ir%2Fbrowse.php%3Fa_id %3D31%26slc_lang%3Dfa%26sid
15. Karmpaliotis D, Michael TT, Brilakis ES, Papayannis AC, Tran DL, Kirkland BL, Lembo N, Kalynych A, Carlson H, Banerjee S,Lombardi W, Kandzari DE, Retrograde coronary chronic total occlusion revascularization: procedural and in- hospital outcomes from a multicenter registry in the United States, Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, 2012 Dec;5(12):1273-9
16. Stephenson, N.L et al. (2000). The effect of foot reflexology on sternotomy pain of patients undergone CABG. Cardiology Nursing Forum, 27, 67-72, http://reflexology.vioygeia.gr/bibliografia.html
17. Ghanbari A.The effect of foot reflexology on pain and physiological parameters after caesarean section in patients referring to Alzahra educational center in Rasht. Available from URL: http://www.irct.ir/searchresult.php? id=1174&number=4
18. Shweta Choudhary PhD, (Dept. of Biophysics), Dr. Guresh Kumar, Dr. Kulwant Singh (Dept. of Biostatistics) , Reflexology Reduces the Requirement and Quantity of Pain Killers after General Surgery, All India Institute of Medical Science (AIIMS), New Delhi, India, http://www.reflexology- usa.org/assets/dr_shweta_research_study.pdf 19. Grealish L, Lomasney A, Whiteman B, Foot massage. A nursing intervention to modify the distressing symptoms of pain and nausea inpatients hospitalized with cancer, School of Nursing, Division of Science and Design, University of Canberra, Australia, 2000 Jun;23(3):237-43, http://www.ncbi.nlm.nih.gov/pubmed/10851775 20. Yang JH (2005), "The Effects of Foot Reflexology on Nausea, Vomiting and Fatigue of Breast Cancer Patients Undergoing Chemotherapy. J Korean Acad Nurs. Feb;35(1):177-185. Korean Department of Nursing, Inje University, Korea. [email protected]
21. Stephenson NL, Weinrich SP, Tavakoli AS, The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer, School of Nursing, East Carolina University, Greenville, NC, USA. [email protected], 2000 Jan- Feb;27(1):67-72, http://www.ncbi.nlm.nih.gov/pubmed/10660924
22. Goshu E, Jin H, Fasnacht R, Sepenski M, Michaud JL, Fan CM, Sim2 mutants have developmental defects not overlapping with those of Sim1 mutants, Department of Embryology, Carnegie Institution of Washington, Baltimore, Maryland 21210, USA, 2002 Jun;22(12):4147-57, http://www.ncbi.nlm.nih.gov/pubmed?term=Jin%20Hui%2C%20199
23. Suthathip Kasedluksame(2005), "The Effect of preoperative information combined with foot reflexology with aromatherapy on unpleasant symptoms in post opened-heart surgery patients," Thesis, Chulalongkorn University, Nursing Science, Thailand (Chanokporn jitpanya, Advisor)
25. Berenson, S. (2006). Complementary and alternative therapies in palliative care. In Textbook of Palliative Nursing, 2nd ed., Ferrell, B.R. & Coyle, N. (eds.), pp. 491-509. New York: Oxford University Press, http://reflexology.vioygeia.gr/bibliografia.html.
1. 9. SIGNATURE OF CANDIDATE :
10. REMARKS OF THE GUIDE :
11. NAME AND DESIGNATION OF
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11.2 CO-GUIDE : SIGNATURE :
11.3 HEAD OF THE DEPARTMENT : SIGNATURE :
12. REMARKS OF THE PRINCIPAL :
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