a mental disorder exists when some internal...
TRANSCRIPT
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA,
PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
JIMCY.N.M
1ST YEAR M.SC NURSING
MENTAL HEALTH NURSING
YEAR 2010-2012
CAUVERY COLLEGE OF NURSING
TERISIAN COLLEGE CIRCLE
SIDHARTHANAGAR
MYSORE
1
RAJIV GANDI UNIVERSITY OF HEALTH SCIENCESBANGLORE, KARNATAKA
1. NAME OF THE CANDIDATE JIMCY.N.M
CAUVERY COLLEGE OF NURSING
TERISIAN COLLEGE CIRCLE
SIDHARTHANAGAR
MYSORE
2. NAME OF THE INSTITUTION CAUVERY COLLEGE OF NURSING,
MYSORE
3. SUBJECT AND COURSE OF STUDY MASTER OF SCIENCE INNURSING – MENTAL HEALTH NURSING
4. DATE OF ADMISSION TO THE COURSE
01-06-2010
5. TITLE OF THE TOPIC EFFECTIVENESSS OF SELF
INSTRUCTIONAL MODULE ON ELDERLY
AGITATED BEHAVIORS AND ITS
MANAGEMENT AMONG CARETAKERS
IN SELECTED OLD AGE HOME AT
MYSORE DISTRICT KARNATAKA
5.1. STATEMENT OF THE PROBLEM A STUDY TO EVALUVATE THE
EFFECTIVENESSS OF SELF
INSTRUCTIONAL MODULE ON ELDERLY
AGITATED BEHAVIORS AND ITS
MANAGEMENT AMONG CARETAKERS
IN SELECTED OLD AGE HOME AT
MYSORE DISTRICT KARNATAKA
PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
2
6. BRIEF RESUME OF THE INTENTED STUDY6.1 INTRODUCTION
“Ageing is a development issue. Healthy older persons are a resource for their,
family, their communities and the economy” - WHO
During these recent 11 years the world has changed, there has been significant demographical
change’s in India’s population due globalization and improved medical facility and lifestyle. The fall of
joint family system and rise in nuclear family system has brought new dimension to the care and
welfare of elderly. Population of people above 60yrs. India has today second largest population of
senior citizens1.
WHO defines “Mental health is a state of well-being in which the individual realizes his or her own
abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to
make a contribution to his or her community2”
So, mental wellness is generally viewed as a positive attribute such that a person can reach enhanced
level of mental health even if they do not have diagnosable mental health condition. This definition of
mental health highlights emotional wellbeing, the capacity to live a full and creative life and the
flexibility to deal with life’s inevitable challenges.3,
Mental illness can affect person’s of any age, race,religion or income. It is not the result of personal
weakness, lack of character or poor upbringing. Mental illness occurs when a state of physical, mental,
social and spiritual well-being is disturbed4.
Aging is the normal process of a time related change, begins with birth and continuous
through life. According to Erick Erickson, this stage is a culmination of many previous intrapsychic and
IPR changes. Continued intellectual, social, and physical activities throughout the life cycle are
important for the maintenance of mental health in late life5.
3
The process of aging also tends to create psychological and social problems for the individual
and the society. The degree of adaptation to fact of aging is crucial to one’s happiness. Failure to adapt
can result in depression, anxiety and agitate behavior and other related psychological problems 6.
Agitation has been defined “inappropriate verbal, vocal, or motor activity that is not explained by
needs”. Nurses should be vigilant in how older adults respond to life events, transitions, and challenges
to their physical and mental well-being in order to initiate appropriate intervention in a timely manner 2.
Hence a Nurse should have a behavioral approach to agitated elderly. The behavioral
treatment of agitation centers on identifying and modifying the physiologic, psychosocial, and
environmental factors that are antecedents of the agitated behaviors8.
Psychiatric Nursing has emerged as a specialized branch of Nursing in the recent past in India.
Psychiatric training for Nurses is essential not only to manage the severely mentally ill or psychotic
patients but also to so many other psychological problems which include elderly anxiety and other
neurotic disorder9,10.
6.2 NEED FOR THE STUDY
“Aging gracefully is a widespread self-esteem challenge”
David Leonhard
People aged 60 and over: about 600 million in 2000,1.2 billion in 5052,and 2 billion in 2050.Currently
about two-third of all older persons are living in the developing world; by 2052 that will rise to 75%.In
the developed world, the very old(age80+)is the fastest growing population group. Women outlive men in
virtually all socities; consequently in very old age the ratio of women and men is 2:12.
Aging scenario of India repots that in the beginning of the last century 12 millions Indian where age
60 years or more. The number of the aged is doubled in the next 60 years to 24 millions. Since then
there has been a large increase in the number of the elderly, to about 56 millions in 1991. The projected
figures for the years 2001 and 2025 are 70 millions and 177 millions respectively 11, 12.
4
An epidemiological studies and community surveys on the elderly in India indicate a varied
prevalence rate of mental illness or psychiatric morbidity ranging from 2.2 percent to 3.7 percent. Most
of these surveys were conducted in Gero-psychiatric clinics; mental health centre located in South India
Towers, Calcutta and Agra and also covered the older people from villages and slum areas 13.
It has, however, been observed that there is a general tendency of psychiatric morbidity to
rise with advancing years. Moreover, for most of the elderly population, these problems can be
subsumed within a general problem of poverty. Although less in number and restricted in scope, such
surveys of the mental health problems of the elderly, nevertheless, brought into focus the need for
conducting interdisciplinary studies14.
Many studies conducted in India and other developing countries reveal that a majority of elderly
people are socially and economically dependent on their family members. They cannot afford to seek
health care themselves. In India although physical, social and psychological health are separated out for
convenience, each impinges can affect psychological health, especially the environment in which they
live13,14.
The Indian subcontinent boasts of our ‘Great Joint Family’ ‘The Traditional family’ system where
we used to respect, care and love our elders, our parents. Due to Globalization and New lifestyle there
is increasing number of abuse. Neglect and abandon case with regards to senior citizens. The gradual
urbanization of rural India is also a new trend to worry. Therefore psycho and social problems of the
elderly needs to be attended urgently1.
The nonspecific neuropsychiatry symptoms of agitation can generate felling of frustration, fear and
helplessness in both the patients and their caregivers. Coping mechanisms may fail and give way to
intolerance as family member try to deal with these problems day after day,. Therefore elderly people
are forced out of their homes and they are made to depend on federally funded services like old age
homes. In old age homes Caring and concern can quickly turn to annoyance, outright anger and even
elder abuse. Caregiver’s lack of understanding and unrealistic expectations compound the problem
some caregivers may see the affected elderly people as manipulative rather than as victims of
5
unavoidable central nerves system changes. Professionals working with the elderly are also not immune
to these feeling 14.
Thus it was evidently felt by the researcher the need to identify 5 the agitation in elderly and select
caretaker of old age homes to educate regarding elderly agitated behaviors and its management.
Growing older cannot be prevented. We begin aging at the time of conception and continue aging
one day at a time12. However, some of the effects of aging can be slowed and even prevented 13.
Prevention in later years requires participating in health education and health promotion activities
designed to reduce the risk of disease
Taking into consideration all the above facts, the researcher felt to develop a self-instructional module
on elderly agitated behaviors and its management among caretakers of old age homes, to suggest the steps
to be taken in order to prevent and minimize some of the adverse behavioral feature of agitation, may be
avoided or diminished.
Hence the following section discusses issues to be considered, the need to develop a research study on
elderly agitated behaviors and its management among caretaker in a selected old age homes at Mysore
district Karnataka.
6.3 STATEMENT OF THE PROBLEM
A Study to Evaluate The Effectiveness Of Self Instructional Module On Elderly Agitated Behaviors
And Its Management Among Caretakers In Selected Old Age Home At Mysore District Karnataka.
6.4 OBJECTIVES
To assess and identify agitation in elderly people.
To assess the knowledge level of caretakers regarding elderly agitated behaviors and its
management.
To develop a self instructional module on elderly agitated behaviors and its management for
caretakers in old age home.
To evaluate the effectiveness of self instructional module on agitated behaviors and its
management among caretakers in old age home.
6
To determine the association between the knowledge regarding elderly agitated behaviors and its
management among caretakers in old age home with selected demographical variables such as
age, sex,locality,education status, qualification etc
6.5. HYPOTHESIS
H0: There is no association between the knowledge level of caretakers in old age home and selected
variables such as age, sex, education status and qualification
H1: The mean post-test knowledge of caretakers in old age home will be higher than the pre-test
knowledge score after administrating the Self instruction module.
6.6. OPERATIONAL DEFENITIONS
Effectiveness
Effectiveness is a measure of the match between stated goals and their achievement15.
In this study ‘effectiveness’ refers to the extent to which self-instructional module has achieved
the effect in the management of elderly agitated behavior as measured by gain in knowledge score.
Self-instructional module
A self contained instructional unit that includes one more learning objectives, appropriate
learning materials and methods necessary learning of specific unit or topic16.
In this study ‘self-instructional module’ refers to the educational material (booklet) prepared for
caretaker of old age homes regarding management of elderly agitated behaviors. This includes the
following aspects: concept of agitated behaviors, identification and management of behaviors
during the initial stage, management of the patient during and after agitated behaviors.
Elderly
The 65 years and older population who is often viewed as an important long term care target
group6.
Agitated behavior
Inappropriate verbal, vocal, or motor activity that is not explained by needs2.
Old Age Home
7
Old age home are meant for senior citizens who are unable to stay with their families or
destitute.2.
In this study old age home is a setting where elderly people are forced by their family member.
Elderly will be taken care only by the caretaker employed in the old age homes.
Care Taker
One who is employed to look after or take charge of goods, property, or a person, a custodian2.
In this study caretaker is meant for those who trained to take care (giving bath, dressing- up, feeding
and severing food etc.) of elderly in old age homes who can’t perform their basic needs.
6.8. CONCEPTUAL FRAME WORK
Theory of Ida Jean Orlando.
Orlando describes her theory as revolving around five major interrelated concepts.
1. Patient behavior
Professional nursing function-organizing principle.
The patient’s presenting behavior- problematic situation.
2. Nurse reaction
The immediate reaction or internal response of the nurse.
3. Nursing action
Nursing process discipline (Deliberative nursing process).
4. Improvement
This theory will be modified and used as conceptual frame work for this study.
6.9. DELIMINATIONS
The study is delimited to elderly people aged above 65yrs who are living in old age home.
The data collection period is limited to 6 weeks only.
6.10. REVIEW OF LITRATURE
Review of literature is an important step in the development of any research project. It helps the
investigators to analyze what is known about the topic and describe methods of inquiry used in earlier
world including their success and shortcomings.
8
Literature refers to the activities involved in searching for information on a
topic as well as the actual written report that summarizes the state of the existing
knowledge on research problems It gives a broad understanding of the problems, keeping those aspects
in mind the investigators probed into the available resource of document,informations and studies on
agitation in elderly and its management.
Review of literature helps in selecting appropriate methodology, developing
tool, analyzing data and relating the findings from one study to another so as to
establish knowledge in a professional discipline from which valid and pertinent
theories may be developed.
Review of literature has been grouped into the following categories based on Agitation and use of
therapy as managements
Prevalence of Agitation in elderly.
Agitation and use of music therapy.
Agitation and use of family presences stimulated therapy.
Agitation and use of bright light therapy.
Agitation and use of Activity therapy.
Prevalence of agitation in elderly.
D Saldanha conducted the study and its aim is to determine the prevalence of dementia and
agitation in elderly of an urban center of Pune and to evaluate the corresponding socio-demographic
correlates along with psychiatric morbidity in the study sample. The number of people over 65 years
numbered 6721 and 2145 of them were randomly selected for a door-to-door survey. They were
initially administered household questionnaire and then subjected to a screening tool . the result findings
revealed that prevalence of dementia and agitation in the sample population of elderly aged above 65
years was 4.1%. Burden of care was associated with caring for elderly with dementia with increasing
severity of agitation behaviours.Aging in Indian culture though a disability is much stressful today in
Indian culture as in others17.
Agitation and use music therapy
9
Gerdner L.A conducted a study to asses the effect of individualized versus classical relaxation music
on the frequency of agitation in elderly persons. The sample for this study consisted of 30 women and 9
men with sever cognitive impairment .Baseline data were collected for 3 weeks. Music intervention were
presented for 30 minutes, two time per week. the modified Cohen Mansfield Agitation Inventory
measured the dependent variables. A repeated measures analysis of variance with Bonferroni post hoc test
showed a significant reduction during and following individual music compared to classical music18.
Jan Goddaer conducted a Study on effects of relaxing music on agitation among nursing home
residents with sever cognitive impairment. 29 nursing home residents with sever cognitive deficits
participated in a 4- week protocol in which, following baseline observations (week1), relaxing music
was introduced (week2), removed (week3), and reintroduced (week4). Subjects were observed in terms
of total number of behaviors of the cohen-Mansfield Agitation Inventory present during a given week,
and the number of behaviors present on the subscales of aggressive, physically nonaggressive, verbally
agitated and significant reduction were observed on the cumulative incidence of agitation 19.
Agitation and use of family presence stimulated therapy.
Clive Ballard conducted a study to assess the effectiveness of brief psychosocial therapy on agitated
elderly with Alzheimer disease. 318 patients with Alzheimer disease (AD) with clinically significant
agitated behavior were taken as samples and treated in an open design with a psychological intervention
(brief psychosocial therapy [BPST]) for 4 weeks. The therapy involved social interaction, family
presences stimulated therapy, or removal of environmental triggers. The study resulted with an
improvement of 5.6 points on total Cohen-Mansfield Agitation Inventory (CMAI; mean [SD], 63.3 [16.0]
to 57.7 [18.4], t = 4.8, df = 317, p < 0.0001). Overall, 43% of participants achieved a 30% improvement
in their level of agitation20.
Garland conducted a study the effectiveness of individualized psychosocial treatment in reducing the
frequency of physically and verbally agitated behaviors in nursing home elderly. 30 nursing home
residents with frequent, severe behavioral disturbances were observed by research staff before, during,
and after multiple, randomized, single-blind exposures to 15-minute audiotapes of simulated family
presence (a conversation prepared by a family member about positive experiences from the past). The
study result was that Simulated presence proved effective in reducing counts of physically agitated
behaviors. And also showed significantly reduced counts of verbally agitated behaviors21.
10
Agitation and use of bright light therapy
A Saltlin conducted a study to test that evening bright light pulses would improve sleep-wake
patterns and reduce agitation in elderly and sleep disorders. 10 inpatients on a research ward of a veterans'
hospital were studied in an open clinical trial. All patients had agitated behavior and sleep disturbances.
After a week of baseline measurements, patients received 2 hours/day of exposure to bright light between
7:00 p.m. and 9:00 p.m. for 1 week. During the baseline week, the treatment week, and a post treatment
week, patients were rated by nurses for agitation sleep-wake patterns, use of restraints, and use of
prescribed-as-needed medication monitors. The study result showed Clinical ratings of sleep-wakefulness
on the evening nursing shift improved with light treatment in eight of the 10 patients. The proportion of
total agitated behavior occurring during the nighttime decreased during the light -treatment week. The
relative amplitude of the circadian locomotor activity rhythm, a measure of its stability, increased during
the light-treatment week22,23.
C.G. Lyketos conducted a study to test the efficacy of bright light therapy in a randomized,
controlled, crossover clinical trial. 15 patients with dementia and agitated behaviors residing in a
chronic care facility were randomized in a crossover design to morning bright light therapy for 1 hour
per day or to a control condition with dim light exposure. Patients were treated in either condition for 4
weeks, followed by 1 week on no treatment, prior to being crossed over to the other condition. The
study result showed that, Patients with dementia in chronic care who exhibit agitated behaviors sleep
more hours at night when administered morning bright light therapy24.
Agitation and use of Activity therapy
Buettner conducted a research to evaluate the responses to 30 handmade recreational tools and
assessed their effect on the conduct of nursing home residents with agitated behaviors. The objects used
were stuffed butterfly, cart for wandering, fishing box, flowers for arranging, laundry for hanging, home
decorator books, muffs, picture dominoes squeezies and tetherball game. These objects were placed on an
open cart. Residents could freely choose from the selection of items on the cart. The preferred objects for
all residents in this study was a tetherball game, which held residents attention for as for long as 20
minutes. The result showed that the warmth of these objects may serve to provide both pleasure and
decreased chilling, with a resulting decrease in agitation25.
11
Mary Lucero, Kijek, Malone, Santos, Hendrix. Developed specific play products as a means of
enhancing the quality of life of individuals with disturbed behaviors. Her products and potential
interactions included a busy box, abacus, stacking cups, Reader’s Digests.spinng board, pat mat, and
curves and waves. The interaction with these objects were varied; The residents could thumb, page, fold,
hold, read. Look, and touch a Reader’sDigest;This approach to play therapy included providing the object
to the resident, demonstrating its use, and guiding the play activity by moving the resident’s hands. Result
of this study indicated that using an effective method of product introducing significantly improved the
resident’s ability to engage in activities with the stimulus object with reduction in disturbed behaviors like
agitation26.
7. MATERIALS AND METHODS OF STUDY7.1 SIGNIFICANCE OF THE STUDY
The study implies to find the level of knowledge regarding elderly agitated behaviors and its
management and to evaluating the effectiveness of self instruction module on elderly agitated behaviors
and its management among caretakers in old age home.
7.2. SOURCE OF DATA
The data will be collected from the caretakers in selected old age home at Mysore district.
7.3. RESEARCH DESIGN
Quasi experimental one group pretest –post test design.
KEYS
01– Pre-test regarding elderly agitated behaviors and its management.
X – Application of Self Instructional Module on elderly agitated behaviors and its management.
02 –Post test knowledge regarding elderly agitated behaviors and its management.
7.4. METHOD OF DATA COLLECTION
12
Pre-test 01 Post-test 02X
Modified Cohen-Mansfield Agitation Inventory scale is used to screen elderly agitated behaviors those
who are living in selected old age home of Mysore districts. And data collection is planned through using
a self developed structured questionnaires to identify pre-test knowledge level among caretakers
regarding elderly agitated behaviors and its management. Self instructional module will be administered
and afer week post test knowledge will be assessed.
Part A : Demographical variables include age, sex, locality, education status, qualification, etc.
Part B : Modified Cohen-Mansfield Agitated Inventory scale to assess and identify elderly
agitated behaviors.
Part C : Self developed structured questionnaire on knowledge regarding elderly agitated
behaviors and its management.
Part D : Self Instruction Module on elderly agitated behaviors and its management.
7.5. SAMPLING PROCEDURE
7.5.1. Criteria for Sampling Selection
Inclusive criteria
Caretakers of elderly agitated people in old age home.
Elderly people above 65years of age.
Exclusive criteria
Caretakers of elders in old age home who are not willing to participate.
7.5.2 Population
The target population selected for this study is caretakers of elders in old age home.
7.5.3 Samples
Caretakers of elderly in selected old age home at Mysore.
7.5.4 Sample size
Sample size consists of 60 samples of caretakers in selected old age home at Mysore.
7.5.5 Sampling technique
Convenient Sampling technique which is a type of non probability sampling.
7.5.6 Setting
The setting for the study is selected old age home at Mysore.
7.5.7 Pilot study
10% of the population size is planned for the pilot study.
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7.6 VARIABLES
Independent Variables
Self Instructional Module on elderly agitated behaviors and its management.
Dependent Variables
Knowledge on elderly agitated behaviors and its management among caretakers in old age
homes.
7.7 PLAN FOR DATA ANALYSIS
Descriptive statistics
Demographical variables and knowledge of caretakers of old age home will be analyzed using
frequency, percentage, mean and standard deviation.
INFERENTIAL STATISTICS
o The pre-test and post test scores would be analyzed by paired t-test.
o Chi-square test will be used to find out the association between the knowledge on elderly
agitated behaviors and its management among caretakers in selected old age home with
selected demographical variables such as age, sex, educational status, qualification etc.
7.8 PROJECTED OUTCOME
The study will enable to identify the knowledge on elderly agitated behaviors and its
management among caretakers of old age home.
The study will help the caretakers of old age home to gain knowledge about elderly agitated
behaviors and its management.
7.9 ETHICAL CONSIDERATION
Yes, Ethical clearance is obtained from the institutions and authorities concerned to the particular
setting and also from ethical committee.
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8.1 LIST OF REFERANCE
1. Chalo (March to) azad maidan Mumbai on 16h august 2010. [online]. 2010 aug 4 [cited 2010,aug3];
An article available from: URL:http://www.silverinning.com.
2. Karen Devereaux Melilio, Susan Crocker Houd. Geropsychiatric and mental health nursing. 1st
edition . Canada : Jones and Barlett publishers; 2005.
3. Mental Health. [online] 2010 June 4 [cited 2010 14]; An article available from: URL:
http://www.wikipedia.org/
4. Mental Health. and illness. [online] 2010 July 1[cited 2010,10]; An article available from: URL:
hhtp://www.mental health about.com.
5. Sankar N, Sathiyavathy N, Sandanlakshmy N. Study on anxiety in the elderly. Nightingale nursing
times. 2009; P. 24-5
6. Elsa Sanatombi Devi,Neenu A, Anu P, Rosemary J. Elderly and depression. The nursing journal of
India. 2007; P. 222-23
7. Cohen-Mansfield J & Billing N. Agitated behaviors in the elderly.A conceptual review. Journal of
the American geriatric society.1986; P. 711-21
8. Lindenmayer J. The pathophysiology of agitation. Journal of clinical psychiatry.2000; P. 5-10
9. Niraj Ahuja. A short textbook of psychiatry. 6th ed . New Delhi: Jaypee publishers; 2006.
10. Nambi. Psychiatry for nurse. 1st edition. New Delhi: Jaypee publishers; 2008.
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http://www.slideshare.com
12. Prakash IJ. Ageing. An Indian perspective. Bangalore University ; 2001.
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13. Michael Zal H. Agitation in the elderly. Psychiatric times. 2006 aug. 16:1.
14. Edwards H. Chapman. Contemplating,caring,coping,conversing.A model for promoting mental
wellness in later life. Journal of gerentological nursing.2004 .P.16-21.
15. Fraser. Effectiveness. [Online]. 1994 [Online] available from: URL:
http://www.qualityresearchinternational.com/glossary/effectiveness.htm
16. Elsa Sanatombi Devi. Manipal manual of nursing education.1st edition.CBS publishers. New
Delhi:2006.P.131
17. Saldanha D, Mani MR, Srivasstav k, Goyal S, Bhattacharya D. An epidemiological study of
dememtia under the age of mental health program. Maharashtra. Pune. Indian J psychiatry[serial
online] 2010[cited 2010 Nov 8);52:131-9. Available from: URL:
http://www.indianjpsychiatry.org/text.asp?
18. Gerdner LA. Effects of individual versus classical relaxation music on the frequency of agitation
in elderly person. International psychogeriatric. 2000 ; P. 49-62
19. Goddaer J. Effect of relaxing music on agitation among nursing home elderly with severe cognitive
impairment. Archives of psychiatric nursing. 1994 ; P.150-58
20. Clive Ballard, Richard Brown, Jane Fossey, Simon Douglas, Paul Bradley, Judith Harcork. et.al.
Brief psycholosial therapy for the treatment of agitation in Alzheimer disease.
American.J.Geriatropsychiatry [serial online] 2009 [cited 2010 Sep17] ; 9:726-33.Available from:
URL:http://lib.bioinfo.pl/Journal.
21. Garland. A study to compare the effectiveness of two individual psychological treatment in
reducing the frequency of physically& verbally agitated behaviors in nursing home elderly.
American Journal of geriatric psychiatry. 2007; P.514-21
22. Evan LK. Sundown syndrome in institutionalized elderly. Journal of the American geriatric society.
1987; P.101-8
23. Satlin A,Volicer L, Ross V, Camphell S. Bright light treatment of behavioral and sleep disturbance
in patients with Azhemer’s diseases. American J. psychiatry [serial online] 1992 [cited 2010 Aug
14].P.1028-33.Avialable from: URL: http://www.ncbi.nlm.nih.gov/pubmed/1353313.
24. Lytesos CG, Lindell Veiel L, Baker A, Steele. A study to test the efficiency of bright light therapy
in a randomnized,cotrolled,crossover clinical trial. Int.J.geriatropsychiatry [serial online] 1999
[cited 2010 Jul].7: P.520-25. Avialable from: URL: http://www.ncbi.nlm.nih.gov/pubmed/1353315.
25. Buettner. A study to evaluate the responses to 30 handmade recreational tools and assessed their
effect on the conduct of nursing home elderly with agitated behaviors. Play therapy with adults. 1st
edition [online] 1999. Philadelphia: British catalog publishers; 2003 [cited 2010].Available from:
URL: http://www.google.co.in/plttf
16
26. Mary Lucero, Kijek, Malone, Santos, Hendix. A study to develop specific play products as a means
of enhancing the quality of life of individuals with agitation.Play therapy with adults.1st
edition[online] 1999.Available from: Philadelphia:British catalog publishers; 2003 [cited 2010].
Available from. URL: http://www.google.co.in/playspecified/ppr
8.2. BIBLIOGRAGHY
1. Denise F, Polit, Cherly Tatano Beck. Nursing research.7th ed. New Delhi :Jaypee
publishers(p)Ltd;2003.
2. Basavanthappa BT. Nursing research.1st ed. New Delhi :Jaypee publishers(p)LTD;2003.
3. Carol L, Macnee . Understanding nursing research, reading and using research in practice.1st edition
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4. Basavanthappa BT. Nursing theories.1st edition. New Delhi: Jaypee brothers medical
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5. Mary C Townsend. Essentials of Psychiatric/Mental health nursing. 1st edition. Canada: F.A. Davis
Company publishers;1999.
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9. SIGNATURE OF THE CANDIDATE
10. REMARKS OF THE GUIDE
11. NAME AND DESIGNATION OF THE GUIDE (IN BLOCK LETTERS)
11.1. SIGNATURE
11.2. CO-GUIDE (IF ANY)
11.3. SIGNATURE
11.4. HEAD OF THE DEPARTMENT
11.5. SIGNATURE
12. REMARKS OF THE CHAIRMAN AND PRINCIPAL
12.1. SIGNATURE
18