SYNOPSIS

ST. JOHNS COLLEGE OF NURSING

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA ANNEXURE 2 PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

NAME OF THE CANDIDATE AND

Miss MADONNA D.C. FERNS 1st YEAR MSc NURSING ST. JOHNS COLLEGE OF NURSING, SARJAPURA ROAD, BANGALORE 34

1.

ADDRESS

2.

NAME OF THE INSTITUTION

ST. JOHNS COLLEGE OF NURSING, BANGALORE MSc NURSING MEDICAL-SURGICAL NURSING

3.

COURSE OF THE STUDY SUBJECT DATE OF ADMISSION TO THE COURSE

4.

MAY 02, 2011

EFFECT OF REFLEXOLOGY ON

5.

TITLE OF THE TOPIC

PAIN AMONG POSTOPERATIVE ABDOMINAL SURGERY PATIENTS.

6. BRIEF RESUME OF INTENDED WORK

6.1 NEED FOR THE STUDY Pain is a human response to illness; it is experienced by patients suffering from a broad spectrum of diseases. 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". Inherent in the definition is the recognition that pain perception, management, and evaluation are influenced by multiple integral factors, including physical, psychological, social, cultural, and environmental perspectives unique to the affected person. Because pain is a subjective and uniquely individual experience, pain management can pose challenges for the patient and health care provider1. Pain after major surgeries is severe. The failure to treat pain is inhumane and constitutes professional negligence. Postoperative patients experience severe pain which may have physiological consequences increasing the stress response to surgery, seen as a cascade of endocrine, metabolic and inflammatory events that ultimately may contribute to organ dysfunction, morbidity, increased hospital stay and mortality. The pain often causes the patient to remain immobile, thus becoming vulnerable to DVT, pulmonary atelectasis, muscle wasting and urinary retention, and thus can adversely affect their prognosis1. Postoperative pain evokes both physiological changes and psychological responses, which suggests that a combination of pharmacological and non-pharmacological approaches can enhance the effect of pain relieving medication. An adjunctive approach can help patients feel a sense of control over pain, which can also influence the patient's satisfaction2,3. Postoperative pain assessment and management remains one of the major clinical challenges confronting health-care professionals. Abdominal surgery tends to be the most painful among all surgery types, and 70% of patients who undergo upper abdominal surgery suffer from severe pain. Nurses play a major role in minimizing pain and discomfort. It is essential for providers and nurses to assess, monitor, and provide pharmacologic and non-pharmacologic interventions for those who complain of pain or discomfort, so that the patient will return to self-care and normal daily functioning in a reasonable amount of time4, 5.

Pharmacological interventions are the primary source of providing pain relief in todays scenario. Analgesics such as morphine sulphate and hydro-morphine have been provided to patients around the clock or as needed for pain. The patient controlled analgesia pump (PCA) is also another way to examine the pattern of patient attempts at self-administration of analgesia so that nurses and providers can figure out the patient's pattern of pain perception4. The present health care system in India under the National Health Policy has laid a lot of emphasis on the merging of complementary and alternative medicine (CAM) along with other standard treatment to provide comprehensive health care. A recent survey by the American Hospital Association indicated that 27% of member hospitals offered complementary and alternative medications (CAMs)6. Use of nonpharmacologic adjunctive analgesics has been endorsed by advisory bodies such as the Anaesthesia Patient Safety Foundation and Institute of Healthcare Improvement and the Joint Commission on Accreditation of Healthcare Organizations7. Non-pharmacologic approaches can often help divert attention from pain to alternate sensory experiences, which can further change the affective component of the pain experience. Non-pharmacological pain management can be an effective pain management tool8. Cognitive and behavioural non-pharmacological approaches have been associated with postoperative pain recovery and can be important approaches, particularly in short hospital stays3. There are various non-pharmacological interventions available which may be employed for pain reduction. These measures include distraction, massage, relaxation exercises, deep breathing, guided imagery, reflexology and repositioning. Such techniques can enhance the effects of analgesics as well as provide the patient with an important sense of control over his or her pain. By providing the patient with a means of control, the nurse is involving the patient in the pain management process8. Reflexology, a complementary approach to pain relief, is a form of bodywork that focuses primarily on the feet. Reflexology has been around for a long time. There is archaeological evidence suggesting the use of reflexology in ancient Egypt, China, and Japan. Four centuries later Celsus, a Roman encyclopaedist, profoundly influenced by Greek medicine, in his book, De Medicina, recorded the practice of rubbing the limbs and the results obtained by this practice. These descriptions are

identical to what is known today as reflexology and two popular adjuncts to reflexology known as referral areas and cross reflexes9. Reflexology had a renaissance in Asia in the 1980s, and the practice remains extremely popular there today. Reflexology came into being in the West in the nineteenth century as European researchers delved into the nervous system and the phenomenon of the reflex. So-called reflex therapies initially were developed for medical use, but soon lost favour to the use of surgery and pharmaceuticals. In the early twentieth century, Dr. William H. Fitzgerald, an ear, nose, and throat physician, brought zone therapy, a form of reflex therapy, to the U.S. Physiotherapist Eunice Ingham had developed a reflex area system by 19389. It has been defined by the Reflexology Association of Canada as A natural healing art based on the principle that there are reflexes in the feet, hands and ears and their referral areas within zone related areas, which correspond to every part, gland and organ of the body. Through application of pressure on these reflexes without the use of tools, crmes or lotions, the feet being the primary area of application, reflexology relieves tension, improves circulation and helps promote the natural function of the related areas of the body. Reflexology is relaxing. It improves circulation, eases pain, and promotes healing throughout the body9. More specifically, reflexology can increase the health of the corresponding organs through the application of pressure to the reflex areas. It has been shown to benefit individuals suffering from back pain, insomnia, arthritis, sports injuries, hormonal imbalances, menstrual problems, stress, headaches, and digestive complaints10. Reflexology has been successfully used alongside medical treatment in postoperative and palliative care. It is theorized that reflexology may work partly because it works on the nervous system to effectively interrupt stress and pain signals and restore the body to equilibrium10. Reflexologists postulate that malfunctioning of an organ or body system leads to deposits of uric acid or calcium crystalline salts. These, in turn, would impinge on the nerve endings on the feet and obstruct lymph flow. Massaging these areas would break down the crystalline deposits so that they can be reabsorbed and eliminated10.

Based on the ample evidence of the effectiveness of reflexology on pain and a personal interest in the subject matter, the investigator wishes to evaluate the effect of reflexology on pain in patients post-abdominal surgeries.

6.2 REVIEW OF LITERATURE

The investigator organized the review under the following headings: SECTION 1: LITERATURE RELATED TO PAIN OF ABDOMINAL SURGERY PATIENTS. SECTION 2: LITERATURE RELATED TO THE EFFECT OF REFLEXOLOGY AS A NON-PHARMACOLOGICAL INTERVENTION ON PAIN.

SECTION 1: LITERATURE RELATED TO PAIN OF ABDOMINAL SURGERY PATIENTS. Postoperative pain consists of a constellation of unpleasant sensory, emotional, and mental experiences associated with autonomic, psychological, and behavioural responses precipitated by the surgical injury. A common misconception is that pain, no matter how severe, can always be effectively relieved by opioid analgesics. It has repeatedly been demonstrated, however, that in a high proportion of postoperative patients, pain is inadequately treated11. A study was done in New Delhi, India on post-operative pain after cholecystectomy: conventional laparoscopic surgery (CLS) versus single incision laparoscopic surgery (SILS). A hundred patients were sampled. Pain scores were assessed using the visual analogue scale. Data were analysed using the students t-test to check statistical significance. Results revealed that post-operative pain in abdominal surgery patients is severe, but that there is no significant difference in pain scores between patients undergoing SILS / CLS, the latter being more painful12. A study was done on 145 patients to assess the immediate postoperative pain level in patients after laparoscopy and laparotomy. Findings revealed that among post-

operative abdominal surgery patients, severe immediate (0-4 hours) postoperative pain was significant in laparoscopic patients (54%), and their pain is more intense, requiring more analgesics than painful patients (46%) after laparotomy13. Another study was done to determine whether pain, depression, and fatigue are significant factors in the return of older adults who had major abdominal surgery to functional status and self-perception of recovery. The study sampled 192 patients which included adults 60 years of age or older who had undergone major abdominal surgery. Data were collected using the Brief Pain Inventory and the Self-Perception of Recovery Scale. Multiple regression was used in the analysis of data. The findings indicated that pain and fatigue are significantly related to patients' self-perception of recovery and functional status. The study suggested that specific interventions to reduce pain need to be evaluated for their impact on the postoperative recovery of older adults14. A study was done in the University of Barcelona, Spain to describe the prevalence and the severity of postoperative pain among a sample of 993 abdominal surgery patients. The most common surgical procedures were inguinal hernia repair, cholecystectomy, appendectomy, bowel resection, and gastric surgery. The data were assessed during the first day after surgery by means of a 6-category rating scale and a visual analogue scale (VAS). Fifty-nine per cent of patients received non-opioid analgesics only, 9% received opioid analgesics only, and 27% received both opioid and non-opioid analgesics. Thirty eight per cent patients rated their maximum pain on the first day as severe to unbearable. The percentage of patients in each centre who suffered severe to unbearable pain varied from 22 to 67%. The study concluded that postoperative pain is severe15.

SECTION 2: LITERATURE RELATED TO THE EFFECT OF REFLEXOLOGY ON PAIN. Pain reduction is a significant result of reflexology work in general as noted in many studies. Most of the studies have been conducted post-operatively. Lessened pain and/or a decrease in the amount of medication, as a result of reflexology, is reported post-surgically for mastectomy, abdominal surgery, gastric and liver cancer,

prostatectomy, open heart and general surgery patients. As noted in one study: even after receiving analgesia, patients with gastric and liver cancer still report moderate levels of postoperative pain. Taiwanese nurses conducted a study of the use of reflexology to relieve pain and anxiety in postoperative patients with gastric cancer and hepatocellular cancer. Less pain and anxiety were reported by reflexology group members when compared to those in the control group. In addition, patients in the intervention group received significantly less opioid analgesics than the control group. The study concluded by recommending reflexology as an excellent means and alternative for reducing pain in patients who have undergone gastric surgeries.10 A study was done in Bangkok to examine the effects of hand reflexology on the levels of pain in postoperative abdominal surgery patients. The sample consisted of 30 post-abdominal surgery patients who were randomized into 2 groups experimental and control. The study employed a simple cross-over design and used the manual of hand reflexology which is an instrument for recording patients personal information, assessing pain perception, satisfaction questionnaires and patients opinions. Vital signs and pain scores before and immediately after the intervention at day 1 and 2 postoperative were assessed. Data were analysed using ANOVA and ANCOVA. Findings revealed significantly lower mean pain score in post abdominal surgery patients after receiving true and mimic hand reflexology at p<0.05. So the study concluded that hand reflexology is considered as a complementary alternative in nursing practice for reducing pain in post-abdominal surgery patients16. Another study was conducted in Rochester, USA to determine the effect of foot reflexology on pain management for thoracic surgery patients. One hundred and sixty patients were sampled. A numerical pain rating scale of 0 to 10 (0 = no pain, 10 = worst possible pain) was used to assess pain scores pre- and post- the intervention. Findings indicated that patients receiving the therapy had significantly decreased pain scores after reflexology (p .001, which is statistically significant). Hence it was concluded that foot reflexology therapy may be an important additional pain management component of the healing experience for patients after thoracic surgery17. A randomized control trial was done in Taipei, Taiwan on effects of reflexotherapy to investigate its efficacy as an adjuvant therapy in relieving pain and anxiety among postoperative patients with gastric cancer. Sixty-one patients were

randomly sampled into two groups. Patients in the intervention group received the usual pain management plus 20 minutes of foot reflexotherapy during postoperative days 2, 3, and 4. Patients in the control group received the standard usual pain management. The short-form McGill Pain Questionnaire, Visual Analogue Scale for pain and the Hospital Anxiety and Depression Scale were used to assess the data. Results indicated that less pain (P < .05) and anxiety over time were reported by the intervention group compared with the control group. In addition, patients in the intervention group received significantly less opioid analgesics than the control group (P < .05). Findings from this study suggest and provide nurses with an additional treatment to offer postoperative gastric cancer patients18. A study was conducted on 45 patients in Korea on the effect of hand reflexology on pain, skin temperature and nursing practice, applied to in-patients in the clinical setting. Data were collected using the VAS to assess pain levels and a questionnaire of nursing care to assess the nursing practice. Five minute hand reflexology therapy was applied to both hands of participant by two research assistants at the same time. The findings showed that after receiving hand reflexology therapy, the subjects showed significant pain relief (t =- 4.94, p =. 0001), improvement in feeling, and an increase in skin temperature, thereby suggesting hand reflexology as an excellent method to reduce pain19. Another study was conducted in Bangkok on 60 patients to determine the effects of foot reflexology on pain level, vital signs, and satisfaction in post-abdominal surgical patients. Using a simple cross-over design, thirtypatients were randomly selected into a control and an experimental group. The former received 30-minutes of supportive-educative care, while the latter received 30-minutes of foot reflexology. Instruments used to assess the degree of satisfaction and the opinion of foot reflexology included the demographic characteristic recording form, the pain assessment form, the vital sign record and a questionnaire. The investigator performed the demographic data collection and the assistants provided the pain assessment and vital signs record at pre-and post- intervention, immediately after the foot reflexology and at 15 and 45 minute intervals afterwards. Paired t-test was used for research analysis. The findings demonstrated that the patients having foot reflexology indicated lower pain scores than the patients receiving supportive-educative care which was highly significant at the 0.01 level. Also, means of heart rate, respiratory rate and

blood pressure in the patients having foot reflexology were lower than in the patients having supportive-educative care with a statistically significant P<0.05. So the study recommended that foot reflexology be considered as a complementary alternative in nursing practice for decreasing post-abdominal surgery pain20. A study was conducted in Stockport, England, on the effect of foot reflexology on patients' perception of care following laparoscopic sterilization as day case patients. This randomized-controlled study employed a sample of 59 women who underwent laparoscopic sterilization and were randomly allocated into two groups. The experimental group received a foot reflexology and analgesia post-operatively, whilst the control group received only analgesia post-operatively. A questionnaire was used to assess pain levels and analgesia taken. The findings showed a significant difference in the mean pain scores experienced by the two groups, such that the experimental group consistently reported less pain following a foot reflexology than the control group21. A study was carried out on foot reflexology among 130 subjects to test if foot reflexology (FR) affects the well-being, voiding, bowel movements, pain, and/or sleep in women who underwent an abdominal operation. The samples were randomised into three groups and were exposed to fifteen minutes of FR, foot/leg massage (FM) or talking respectively for five days. Findings revealed that foot reflexology and foot massage showed significant results in the subjective measures of well-being (p<0.006), less pain (p=0.011) and sleep22. Another study was done in Beijing on reflexology being applied as a painkiller. The sample consisted of 60 individuals who were experiencing pain. Sessions lasted 20 minutes to 40 minutes. 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. Following one session of foot reflexology, 18 of the 60 were healed. 11 were healed following 2 or 3 sessions, 22 were effectively treated after 2 or 3 sessions. Results revealed that post-surgical patients who receive foot massage and medication report "significantly less" agony than those on painkillers alone23. Thus the above literature review has thrown light on the effectiveness of reflexology on pain.

6.3 PROBLEM STATEMENT A study to assess the effect of reflexology on pain among post-operative abdominal surgery patients in a tertiary care hospital, Bangalore..

6.4 OBJECTIVES OF THE STUDY 1) To assess the level of pain among abdominal surgery patients in both the experimental and control groups before the intervention. 2) To compare the level of pain between the experimental and control groups after the intervention. 3) To determine the association of the level of pain with selected baseline variables in both the experimental and control groups.

6.5 OPERATIONAL DEFINITIONS

Effect According to the Oxford English Dictionary, it implies, a change which is a result or consequence of an action. In this study, it refers to the ability of reflexology, as a non-pharmacological intervention, to bring about a change in the pain level among post-operative abdominal surgery patients, as measured using a Numerical Pain Intensity Scale rated by the patient.

Reflexology Reflexology is the practice of applying pressure to the feet and hands utilizing specific thumb, finger and hand techniques without the use of oil, cream or lotion based on a system of zones and reflex areas that reflect an image of the body on the feet and hands with a premise that such work effects a physical change in the body.9

In this study, it refers to the application of pressure to the upper and the lower arch of the feet of the patient for a duration of 10 minutes per foot, based on a system of zones and reflex areas that reflect an image of the body on the feet, and which will be administered by the investigator who has undergone a basic training in reflexology.

Pain According to the International Association for the Study of Pain (IASP), pain is defined as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." In this study, pain refers to the unpleasant experience perceived by the postoperative abdominal surgery patients, as measured by the scores rated by them on a Numerical Pain Intensity scale.

Postoperative patients It refers to those patients who will undergo abdominal surgery such aslaparotomy, appendisectomy, hernioplasty, herniorraphy (mesh repairs), spleenectomy, esophagogastrectomy, gastro- and intestinal surgeries 48 hours after surgery.

Selected baseline variables In this study, it refers to the age, gender, education, occupation, previous exposure to reflexology, past history of surgeries, diagnosis, surgery undergone presently and present medications being received.

6.6 ASSUMPTIONS 1) Pain is a subjective feeling, expressed based on different tolerance levels and unique to individuals. 2) Post-operative patients experience some amount of pain.

3) Reflexology may have some effect on pain.

6.7 DELIMITATIONS The study is limited to adult patients who have undergone abdominal surgeries and are in the male and female surgery inpatient units of SJMCH, Bangalore.

6.8 PROJECTED OUTCOME The study findings will reveal 1) The level of pain experienced by the post-operative abdominal surgery patients. 2) The effect of reflexology as a non-pharmacological measure on pain. 3) The beneficial use of reflexology as a complementary therapy for pain relief and it can be implemented by nurses in the clinical setting.

6.9 HYPOTHESES H1: There will be a significant difference in the level of pain between the experimental and control groups after the intervention at 0.05 level of significance. H2: There will be a significant association of the level of pain of post-operative abdominal surgery patients with their selected baseline variables at 0.05 level of significance.

7 MATERIALS AND METHODS

7.1 SOURCE OF DATA 7.1.1 RESEARCH DESIGN A quasi-experimental pre-test post-test control group design will be used for the study.

7.1.2 SETTING The study will be conducted in the surgery wards (male and female) of St. Johns Medical College Hospital (SJMCH), Bangalore. SJMCH is a 1250-bedded multispeciality, tertiary care hospital with an overall bed occupancy of 82-85%.On an average, there are about 80 - 85 abdominal surgeriesperformed in a month.

7.1.3 POPULATION The population is the post-operative abdominal surgery patients in the in-patient surgical wards of SJMCH, Bangalore.

7.2 METHOD AND DATA COLLECTION 7.2.1 SAMPLING PROCEDURE The sampling procedure used in this study will be the non-probability purposive sampling technique.

7.2.2 SAMPLE SIZE The total sample size will be 30 in experimental and 30 in control groups (total 60).

7.2.3 INCLUSION CRITERIA FOR SAMPLING Adult patients 1) 48 hours after surgery. 2) capable of giving adequate responses to pain.

7.2.4 EXCLUSION CRITERIA FOR SAMPLING Patients who are 1) unconscious or critically ill. 2) on epidural anaesthesia and sedatives. 3) with ulcers on the foot, with diabetic peripheral neuropathy 4) with cellulitis, oedema 5) with amputated limbs. 6) have undergone laparoscopy.

7.2.5 INSTRUMENTS USED Section 1: Interview schedule to obtain the demographic data. Section 2: Numerical pain intensity rating scale

7.2.6 DATA COLLECTION METHOD After obtaining administrative permission, the subjects will be identified according to the inclusion and exclusion criteria by the purposive sampling technique. The samples will then be randomly allocated into the control and the experimental groups by flipping a coin. Initial rapport will be established, the purpose of the study will be explained to the subjects, and informed consent will be obtained. The demographic data will be collected using an interview scale. The pre-test pain levels will be assessed in both the experimental and control groups. The intervention (i.e., reflexology) will then be administered to the experimental group by the investigator who has already undergone a certification course in reflexology, 48 hours after the surgery for 3 consecutive days. The intervention will begin 3 hours after the administration of analgesics, by the investigator for both the feet, 10 minutes for each foot. The post-test pain levels will be assessed immediately and at 30 minutes after the intervention.

7.2.7 PLAN FOR DATA ANALYSIS Data analysis is planned to include both descriptive (such as mean, median and standard deviation) and inferential statistics (such as t-test).

7.3

DOES

THE

STUDY

REQUIRE

ANY

INVESTIGATION

OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY. Yes, the study does require the use of an intervention, i.e., foot reflexology.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3? Administrative permission and ethical clearance will be obtained from the research committee of SJCON, Bangalore. Ethical clearance will also be obtained from the Institutional Ethical Review Board (IERB) prior to the study.

REFERENCES

1. Chaturvedi S, Chaturvedi A. Post-operative pain and its management. Indian Journal of Critical Care Medicine. 2007 Dec; 11(4):204-211 2. Procedure Specific Post-operative http://www.postoppain.org Pain Management. Available at

3. Siriburanonta S, Toskulkao T, Satayawiwat W. The development of a clinical nursing practice guideline for pain management in elderly patients undergoing major abdominal surgeries. Journal of Nursing Sciences. 2009 Dec; 27(3):33 4. Method of pain relief in patients after abdominal / pelvic surgery. Available at www.freshpatents.com (U.S. patent application Ser. No. 11/078,76)

5. Rejeh N, Vaismoradi M. Perspectives and experiences of elective surgery patients regarding pain management. Nursing and Health Sciences. 2010; 12: 67-73 6. National Center for Complementary and Alternative Medicine. Available at http://nccam.nih.gov/2006_fall/hospital.htm

7. Anesthesia Patient Safety Foundation. Available at http://www.apsf.org/2007

8. Pearl T S. Non-pharmacological pain management is also an effective tool. 2001 May: 1-5 9. Reflexology. www.wikipedia.com

10. Kunz, Kevin; Kunz, Barbara. The Complete Guide to Foot Reflexology. Reflexology Research Project (1993). 11. Spencer S L, Henrik K. Postoperative pain: basic surgical and postoperative consideration. 2009 Jan: 1-12

12. Prasad A, Mukherjee K A, Kaul S, Kaur M. Postoperative pain after cholecystectomy: conventional laparoscopy versus single incision laparoscopic surgery. 2011 March; 7(1): 24-27 13. Ekstein P, Sagie B et al. Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate postoperative period. Annals of Surgery. 2006 Jan; 243(1): 41-46.

14. Margarete L Z. Correlates of recovery among older adults after major abdominal surgery. Nursing research. 2004; 53(2): 99-106.

15. Vallano A, Aguilera C, Arnau J M et al. Management of post-operative pain in abdominal surgery in Spain: a multicentre drug utilization study. Journal of Clinical Pharmacology. 1999 June; 47(6):667-673

16. Chatchamon D, Kimpee S, Toskukao T, Asdornwised U. The effects of hand reflexology on the levels of pain in postoperative abdominal surgery patients. Journal of Nursing Sciences. 2009; 27(2): 49-58

17. Dion L, Rodgers N, Cutshall S M, Cordes M E, Bauer B, Cassivi S D et al. Effect of Massage on Pain Management for Thoracic Surgery Patients. International Journal of Therapeutic Massage and Bodywork. 2011 June; 4(2)

18. Tsay S, Chen H, Chen S, Lin H, Lin K. Effects of reflexotherapy on acute postoperative pain and anxiety among patients with digestive cancer. Cancer Nursing. April 2008; 31(2):109-115

19. Caption S Y, Hahyejeong H C, Yiyoungsun S L, Kim D S, Yimyeongsuk M S. The effect of hand reflexology on pain, skin temperature and nursing practice. Korea Journal of Nursing Education. 2006 Jan; 12(2):178

20. Sarunya H. Effects of foot reflexology on pain level, vital signs, and satisfaction in post-abdominal surgical patients. Mahidol University, 2003. Unpublished MSc Nursing Thesis.

21. Hulme J, waterman h, Hillier V F. The effect of foot massage on patients' perception of care following laparoscopic sterilization as day case patients. Journal of Advanced Nursing. 1999 August; 30(2): 460-8 22. Kesselring A, Spichiger E, Muller M. Foot reflexology: an intervention study. 1998 August; 11(4):213-8

23. Jin H. Reflexology applied as a pain-killer - observation of 60 cases. Beijing International Reflexology Conference Report, China Reflexology Association, Beijing 1998: 86-88

SIGNATURE OF THE CANDIDATE: REMARKS OF THE GUIDE: NAME AND DESIGNATION OF

9 10

10.1 GUIDE:

MRS. BINDHU MATHEW ASSOCIATE PROFESSOR MEDICAL-SURGICAL NURSING ST. JOHNS COLLEGE OF NURSING

10.2 SIGNATURE:

__________________________

10.3 CO GUIDE :

DR. L.N. MOHAN PROFESSOR DEPARTMENT OF SURGERY ST. JOHNS MEDICAL COLLEGE HOSPITAL

10.4 SIGNATURE : 11 11.1 HEAD OF THE DEPARTMENT:

_________________________ MRS. MADONNA BRITTO PROFESSOR AND H.O.D MEDICAL-SURGICAL NURSING ST. JOHNS COLLEGE OF NURSING ___________________________

11.2 SIGNATURE: 12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL: 12.2 SIGNATURE :

___________________________