Journal of Nursing Science Practice, Research and Advancements

Volume 1 Issue 1

Cerebro Vascular Accident (CVA)-A Medical Case Study

Sophia G.
Lecturer, Department of Medical Surgical Nursing, DR. B.R. Ambedkar Institute of Nursing,
Dr. B. Ramch Campus, Bangalore, India
Email: Sophiageorge11@gmail.com
DOI: http://doi.org/10.5281/zenodo.2548987

Abstract
Objectives: To perform a health assessment, identify the nursing needs and prevent
complication, formulate nursing diagnosis, provide comprehensive nursing care, learn about
cerebro vascular accident and its management teach family members and patients in detail
about follow-up care. Methods of collection: case sheet, wife. Sample: MICU. Setting:
Government Rajaji hospital, Madurai. Conclusion: By this care study, I got an opportunity to
provide comprehensive nursing care to my client who had cerebrovascular accident. It is of
paramount importance for the nurses to become competent in providing nursing care for the
patients with these problems.

Keywords: CVA patient, IMCU, Govt. Rajaji hospital

INTRODUCTION client with cerebro vascular accident.

Stroke is a worldwide health problem. It  To formulate nursing diagnosis for the
makes an important contribution to client with cerebro vascular accident.
morbidity and mortality and disability [1-  To provide comprehensive nursing
4]. WHO defines stroke as rapidly care to patient with cerebro vascular
developing clinical signs of focal accident
disturbance of cerebral function, lasting
 To learn about cerebro vascular
more than 24 hours and leading to death
accident and its management in detail.
[5-7].
Although the prevalence of stroke appears  To identify and prevent complication.
to be comparatively less in India than in  To teach family members and patients
developed countries, it is less likely to in detail about follow-up care.
increase proportionally with the increase in
life expectancy [8-10]. HISTORY COLLECTION
Ward: Intensive Medical Care Unit
As I was interested in studying central Medical diagnosis: Cerebro vascular
nervous system disorders and caring accident
patients with cerebro vascular accident, I
have selected a patient with CVA for my Chief Complaints
medical case study in critical care nursing Patient was brought to hospital in
[11]. The material is presented here to unconscious state with tracheotomy (on
provide an overall frame work of nursing mechanical ventilation).
care for patient with cerebro vascular
accident [12]. History of Present Illness
Patient was apparently normal before 7
OBJECTIVES
days. He developed giddiness and became
 To perform a health assessment of the
unconscious, and was taken to a private
client with cerebro vascular accident.
hospital where he was diagnosed having
 To identify the nursing needs of the
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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

posterior inferior cerebral artery infarct. Personal History

On admission his GCS was He was mixed type diet. Patterns of rest
5\15,bp=150\90, pulse rate-100\min and and sleep, rest 2 hours in afternoon/6hrs,
spo2-100%.he was treated for the infarct night sleep. His hobby is watching
appropriately and he was extubated and television. His Activities of daily living
shifted to ward, as his GCSfurther was nil. His Bowel and bladder habits
deteriorated and showed signs of constipated frequently, change in
aspiration he was again shifted to ICU and consistency of stools, Bladder-normal. He
reinsulated. Under IV sedation was Alcohol / smoker, consumes brandy 3-
tracheostomy was done but he was
4 times a week amount varies, smokes
discharged again medical advice from
cigarette 1 packet\day brand varies for past
private hospital.
20 years.

Past Medical History

Spiritual History
He is a known case of hypertension on
He belongs to Hindu family. He is going
irregular treatment.
temple regularly for festival occasion. He
Not a known case of pulmonary
tuberculosis, bronchial asthma, coronary is having faith in God.
artery diseases, diabetes mellitus, chronic
kidney disease. No drug allergy. Environmental History
Patient is living in a village for his own
Past Surgical History house. There is adequate water, lightening
Patient not suffered from any major illness and electrical facilities are available. There
before or undergone any surgery. are using a open drainage system so there
is more chance of getting communicable
Family History diseases.
He lives as a nuclear family along with his
wife and child. Non-Consanguineous type PHYSICAL ASSESSMENT
of marriage, No family history of diabetes General Appearance
mellitus, hypertension, epilepsy asthma Consciousness: stuperous
etc.
Body built: Moderately built
Activity: nil
Socio-Economical History Orientation: Not Oriented to Time, Place
Patient is living in own house they are and Person.
getting corporation water supply. They are
getting good ventilation and adequate SYSTEMIC EXAMINATION
lightening and electrical facilities are Central Nervous System
available. He is working as an auto-driver Stuperous, responds to deep painful
they are earning rupees 3000/-per month. stimuli
Not oriented to time, place and person
They are lower middle class family.
GCS- 5\15

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

Cranial Nerve Assessment

Olfactory:
Optic:
Oculomotar:
Trochlear:
Trigeminal:
Abducent:
Facial: cannot be tested
Vestibulocochlear:
Glossopharyngeal:
Vagus:
Accessory:
Hypoglossal:

Spinomotor System
Table 1:
RIGHT LEFT
BULK N N
TONE + _
POWER _ _
REFLEX + +
PLANTAR _ _

Respiratory System Genito Urinary System

Inspection: on tracheotomy, mechanical CBD present connected to urine bag, urine
ventilation-SIMV mode concentrated.
Palpation: Trachea in midline,
Auscultation: vocal frem it us normal, Musculo Skeletal System
bilateral air entry normal Paralyzed
Percussion: Normal resonance
Endocrine System
Cardiovascular System No thyroid enlargement
Inspection: No visible pulse, distended No intolerance to heat or cold
neck veins, no central or peripheral
cyanosis. Integumentary System
Brown complexion, no scabies, skin
Palpation: Pulse rate86/minute. turgor normal
Percussion: Normal resonance
Auscultation: S1S2 heard, No murmur VITAL SIGNS
present Temperature: 98.6 degree F
Pulse: 84/ MINUTE
Gastrointestinal System Respiration: 24/ minute intubated on
Inspection: No scare, lesion mechanical ventilator SIMV mode
Auscultation: Bowel sounds heard in all Blood Pressure: 240/120MMHG
four quadrants Pain Level: cannot be tested

Palpation: Soft, tender, no palpable mass,

organomegally Weight: 50kg
Percussion: No fluid or gas collection Height:154cm

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

INVESTIGATIONS
Investigations Patient value Referral value Remarks
Hemogram:
Haemoglobin 10.7% 12-l4gm% decreased
Total count 7,500 cells/mm 4,000-11,000 within normal limits
cells/mm
Differential Count:
Polymorphs 60% 50% - 70% normal limits
Lymphocytes 46% 30% - 60% Normal limits
Eosinophils 3% 1% - 4% Normal limits
Normal limits

Blood glucose 78mgs% 80-120mgs% Normal limits

Normal limits
B. Urea 50 mg 20-40mg
Sr. Creatinine 1.2 mg 0.7 - 1.5mg Normal limits Normal
limits Normal limit
Liver function test: Normal limits
T.Billirubin 8.7umol/L 5 – 17 umol/L
Direct billirubin 2.6umol/L 1.7 – 3.7 umol/L
Total protein 7.0 g/dl 6.0 – 8.0 g/dl
Albumin 4.3g/dl 3.5 – 5.5g/dl

ECG: LVH with strain

ECHO: Normal LV systolic function.

CHEST X-RAY
Congestion with mucus

CT SCAN
Revealed acute posterior inferior cerebral artery tentorial infarct.
Name of the Drug,
Indications Nursing
Dosage, Route & Action Side effect
Responsibility
Frequency
Obtain a history to
Headache, dizziness,
determine previous
diarrhea, glossitis,
Binds to Perioperative use of antibiotics and
psedomembraneous
Inj. cefriaxone 1gm bacterial cell prophylaxis, intra the side effects.
colitis,
IV Bd wall membrane abdominal Assess for infection at
thrombocytopenia,
(ANTIINFECTIVE) causing cell imfections and beginning and
proteinuria,
death. other infections throughout
vaginitis, pruritus,
Observe for s\s of
nephrotoxicity
anaphylaxis
Headache, dizziness,
Dried acting confusion, ataxia,
Inj. Metrogyl 400mg amoebicide, convulsion, dry Check vision if long
Prophylactic
IV Tds trichomonacide, mouth, metallic term use, monitor
against bacterial
(ANTI binds, degrades taste, nausea, intake and output
infections
MICROBIAL) DNA in vomiting, albumin renal function
organisms urea, decreased
libido, pruritis,
Tab.clopidrogrel 75 Reduction of Abdominal pain, Monitor for
Inhibits platelet
mg oral od atherosclerotic pruritis, purpura, thrombocytic purpura
aggregation
(ANTIPLATELET events (Myocardial Chest pain, edema. Monitor CBC and

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

AGENT) infarction, stroke) differential platelet

count
Block the
enzyme that Vertigo,
Maintain blood
Tab. Enalpril 2.5mg normally Hypertensive alone hypotension,
pressure chart
oral bd converts or for patient with diarrhea, abdominal
Monitor blood counts
(ACE INHIBITORS) angiotensin I to diabetes and pain, taste
with differential
the potent hypertension. disturbances,
counts.
vasoconstrictor protenuria
angiotensin II.
Adjunct to diet
therapy in
management of
Tab.atorvastatin10mg
hypercholesterolem
H.S\oral Inhibits(HMG- Constipation, flatus, Obtain a diet history
ia
(LIPID LOWERING COA)reductase rashes, heartburn Monitor LFT,AST.
Reduction of lipids
AGENT)
and reduces the
risk of M.I and
stroke.
Assess patient for
soreness, headache, epigastric or
diarrhea, itching, abdominal pain and
Inhibits Short term dizziness, frank or occult blood
histamine at H2 treatment of hallucinations, in the stool, emesis, or
Inj. Ranitidine IV
receptor site in duodenal ulcers, Arrhythmias, gastric aspirate.
Tds
parietal cells heartburn, and Altered taste, black Inform patient that it
(H2 RECEPTOR
which inhibits treatment of stress tongue, constipation, may cause drowsiness
ANTAGONIST)
gastric acid induced gastro dark stools, or dizziness.
secretion. intestinal bleeding. diarrhea, drug- Inform patient that
induced hepatitis, increased fluid and
nausea fiber intake may
minimize constipation
Increase the
Adjunct in
osmotic Transient volume
Intravenous fluids: treatment of acute
pressure of expansion, Monitor vitals, intake
1 pint RL oliguric renal
glomerular pulmonary edema, output chart, dyspnea,
Mannitol –osmotic failure, edema,
filtrate and increased potassium crackles.
diuretics increased ICP or
excretion of level.
IOP
water

DISEASE CONDITION CEREBRO system (PNS). The CNS is composed of

VASCULAR ACCIDENT the brain, the cranial nerves, and the spinal
Definition cord. The PNS is made up of the nerves
The sudden death of some brain cells due that exit from the spinal cord at various
to lack of oxygen when the blood flow to levels of the spinal column as well as their
the brain is impaired by blockage or tributaries. The autonomic nervous system
rupture of an artery to the brain. A CVA is (divided into the sympathetic and
also referred to as a stroke. parasympathetic nervous system) is also
considered to be a part of the PNS and it
REVIEW OF ANATOMY AND controls the body's many vegetative (non-
PHYSIOLOGY OF BRAIN voluntary) functions.
INTRODUCTION
The human nervous system is made up of Brain
two main components: the central nervous The human brain serves many important
system (CNS) and the peripheral nervous functions ranging from imagination,

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

memory, speech, and limb movements to components and their functions are listed
secretion hormones and control of various below.
organs within the body. These functions Brain Cells, Cerebrospinal Fluid,
are controlled by many distinct parts that Ventricles, Brainstem, Thalamus,
serve specific and important tasks. These Cerebellum, Cerebrum

Figure 1: Structure of the Brain

Causes 2. High blood pressure

1. Thrombosis 3. Diabetes mellitus
2. Hardening of the artery 4. Alcoholic
3. Cholesterol and Calcium deposit on the
wall of the artery PATHOPHYSIOLOGY
4. Embolus
5. Aneurysm
6. Cerebral hemorrhage

Risk Factors
1. Chronic smoker

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

CLINICAL MANIFESTATIONS
Table 2:
BOOK PICTURE PATIENT PICTURE
1. The most common symptom is weakness or paralysis of Paralyzed and complete loss of movement
one side of the body with partial or complete loss of
voluntary movement or sensation in a leg or arm. -
2. There can be speech problems and weak face muscles,
causing drooling. -
3. Numbness or tingling is very common.
4. A stroke involving the base of the brain can affect balance, unconscious
vision, and swallowing, breathing and even
unconsciousness. History collected
DIAGNOSTIC EVALUATION: Physical examination done
 Medical history
 Physical examination Revealed acute posterior inferior cerebral artery
 A CAT scan (a special X-ray study) of the brain is often territorial infarct
done to show bleeding into the brain; this is treated
differently than a stroke caused by lack of blood supply. A Normal LV systolic function
CAT scan also can rule out some other conditions that may
mimic a stroke. Not done
 A soundwave of the heart (echocardiogram) may be done
to look for a source of blood clots in the heart.
 Narrowing of the carotid artery (the main artery that
supplies blood to each side of the brain) in the neck can be
seen with a soundwave test called a carotid ultrasound

Differential Diagnosis
1. Subdural hematoma
2. Brain tumor
3. Viral encephalitis
4. Dehydration or an imbalance of sodium, calcium, or glucose

Treatment
 Early use of anticoagulants to minimize blood clotting has Not given
value in some patients.
 Treatment of blood pressure that is too high or too low may be Blood pressure treated with Tab. Enalpril
necessary. (Lowering elevated blood pressure into the normal 2.5mg oral bd
range is no longer recommended during the first few days
following a stroke since this may further reduce blood flow Not given
through narrowed arteries and make the stroke worse.)
 The blood sugar glucose in diabetics is often quite high after a Tab.clopidrogrel 75 mg oral od given.
stroke; controlling the glucose level may minimize the size of a
stroke. Patient on mechanical ventilator SIMV mode
 Drugs that can dissolve blood clots may be useful in stroke
treatment.
 Oxygen is administered as needed.

REHABILITATION of a general hospital and in a nursing

When a patient is no longer acutely ill facility.
after a stroke, the aim turns to maximizing
the patient's functional abilities. The rehabilitation process can involve
speech therapy to relearn talking and
This can be done in an inpatient swallowing, occupational therapy for
rehabilitation hospital or in a special area regaining dexterity of the arms and hands,

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

physical therapy for improving strength government publication.

and walking, etc. Orem’ theory consists of 3 related theories,
collectively referred to as Orem’s general
The goal is for the patient to resume as theory of Nursing.
many of their pre-stroke activities as
possible. Orem’s conceptual framework for
nursing
NURSING THEORY APPLICATION Self Care Theory
Orem’s General theory of Nursing 1. Self care
Introduction 2. Self care agency
Developed by Dorothy E. Orem. Orem 3. Self care requisites
first published her concept of Nursing as 4. Therapeutic self care demand
providing for an individual’s self-care in
1959 in Guides for Developing Curricula Self Care Deficit Theory
for the Education of practical Nurses” a Nursing System Theory

BASIC CONDITIONING FACTORS

Age 48 years

Gender Male

Health state Disability due to health condition, therapeutic self care demand

Sociocultural orientation Formal education up to high school, Indian, Hindu

Health care system Institutional health care

Family system Nuclear family, staying with his family members

Patterns of living Along with wife ,son and daughter

UNIVERSAL SELF-CARE REQUISITES

Air On mechanical ventilation SIMV mode
Fluid intake is not sufficient.
Water
Turgor normal for the age
Food Hb – 9.4 gm%, Food intake is not adequate

Elimination On CBD, no bowel movements

Activity/ rest unconscious

Social interaction Poor communication due to loss of consciousness

Prevention of hazards Need instruction on hygiene and diet and about follow - up care

DEVELOPMENTAL SELF-CARE REQUISITES

Maintenance of Not Able to feed self , Difficult to perform the dressing, toileting etc
developmental environment
Prevention/ management of the Feels that the problems are due to her own behaviors ,unconscious
conditions threatening the normal
development

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

OREM’S CONCEPTUAL FRAMEWORK FOR NURSING

NURSING DIAGNOSIS 6. Risk for impaired skin integrity related

1. Impaired gas exchange related to to immobility
decreased oxygen supply as evidenced 7. Interrupted family processes related to
by ABG analysis health crisis as evidenced by
2. Ineffective Breathing Pattern related to verbalization
hypoventilationa evidenced by vital 8. Disturbed thought process related to
signs impaired cerebral functioning
3. Ineffective cerebral tissue perfusion  Subjective data: patient unconscious,
related to interrupted blood flow as his attended complaints of diaphoresis,
evidenced by increased intra cranial initially confused, nasal flaring
pressure  Objective data: unconscious
4. Self care deficit related to inability to GCS:5\15,on mechanical ventilation-
move limbs as evidenced by dull SIMV mode, bilateral coarse
grooming crepitation present
5. Risk for imbalanced fluid volume  Nursing diagnosis: Impaired gas
related to inability to take in fluids by exchange related to decrease oxygen
mouth (fluids and medications supply as evidenced by ABG analysis.
administered)  Goal: Gas exchange will be improved.

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

Interventions Implementation Rationale Evaluation

Assess patients respiratory rate, On mechanical ventilator rate- Help to plan care
depth, rhythm 18breaths\minute,spo2 -100% The patient was
Maintained ABG
Auscultate breath sounds every Bilateral air entry normal, Help to plan care values between
one to two hours and as needed. coarse crepitation present 35-45mmhg

Ensure patent airway and assess Patient on tracheostomy and Prevent cerebral
the need for suctioning(hyper SIMVmode hypoxia
oxygenate before suctioning)

Monitor ABG’S and notify the ABG value:paco2=45mmhg, To prevent

physician of significant changes complications and
initiate treatment
Assist with turning every two Planned every two hourly Promotes lung
hours with in limits of patients turning drainage and alveolar
status expansion.

Monitor intake\output chart Intake output maintained for mobilization of

secretions and avoid
fluid overload
Subjective data: unconscious, his wife complaints of diaphoresis, patient not responding to
commands
Objective data: patient unconscious GCS-5\15.bilateral pupil 2mm reacting to light
Nursing Diagnosis: Ineffective cerebral tissue perfusion related to decreased cerebral blood
flow as evidenced by increased intra cranial pressure.
Goal: cerebral tissue perfusion will be maintained

Plan of Action Implementation Rationale Evaluation

GCS=5\15 To obtain baseline The patient was
Assess neurological status data maintained Tissue
hourly perfusion
Determine presence of changes Unconscious ,Quadriplegia behavioral changes
in cognition, vision, or present indicative of
sensory/motor responses, ineffective
hemiparesis, headache, problems cerebral perfusion
with speech and swallowing
Evaluate blood pressure and BP chart maintained To assess any
maintain chart complication and
prevent it

Monitor fluid and electrolyte Intake output chart

status. maintained Imbalances have a
direct bearing on
brain perfusion and
function
Note history of syncope, Collected history regarding Suggests conditions
brief/intermittent periods of syncope such as orthostatic
confusion/blackout. hypotension,
syncope, TIA.
Administer iv mannitol as Administered iv mannitol To relieve increased
prescribed 150ml bd as prescribed intracranial pressure

Administer medications as Administered tablet. enalpril to treat underlying

indicated 2.5mg bd for reducing blood condition
pressure

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 Journal of Nursing Science Practice, Research and Advancements
Volume 1 Issue 1

Involve others who have Involved another patient Provides role model and
same problems and needs who is suffering from sharing of information.
carcinoma oesophagus and
allowed them to share their
concerns

Subjective data: patient unconscious, his wife complaints that she couldn’t move her husband
alone for meeting his self needs
Objective data: unable to move his hands and legs (quadriplegia), unconscious, NG tube
present, on ventilator
Nursing diagnosis: self care deficit (hygiene, toileting, grooming, feeding) related to stroke
sequale
Goal: self care will be maintained.
Plan of Action Implementation Rationale Evaluation
Assess the level of self Assessed the self care To obtain baseline data
care deficit needs of the patient
Provide oral care, bed Oralcare, bedbath and back To maintain and meet
bath and back care care given basic needs
Provide catheter care Catheter care given To prevent urinary tract
infection
Administer nasogastric Feeding given through To meet nutritional needs Self care needs satisfied
feeding as ordered nasogastric tube as ordered
Administer medicines to Administered dulcolax To induce elimination
maintain bowel suppository as ordered. and prevent constipation.
elimination

HEALTH EDUCATION Nutrition

Explained about the disease condition and  Advised the care giver to give liquid
the available treatment modalities and the diet
prognosis of the disease.  Advised to avoid solid foods until
swallowing is stabilized
Personal Hygiene  Advised the care giver the importance
 Advised the care giver regarding of feeds rich in nutrients.
providing oral care
 Importance of sponge bath and back Follow Up
care 1. Advise about the importance of follow
 Demonstrated eye care and instillation up care.
of eye drops 2. Teach about the next schedule of visit.

Medication RECORDING AND REPORTING

Advice to take regular medication and also Daily Care and Nursing Intervention
advised not to stop or reduce the medicine Care Given
without Doctor’s order.  Monitoring the vital signs.
 Temperature: 370C
Exercise  Pulse: 84 beats/per/mts
 Advised the care giver the importance
 Respiration: 22 breath/per/mts
of passive exercises and frequency of
position change.  Blood pressure: 110/70 mm of Hg
 Advised to do mild passive exercise  Back care morning and evening
 Advised the family members to assist  Position changed every second hourly
the patient in doing passive range of  Passive exercise given Upper
motion exercise. Extremities

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 Position changed every 2 hourly  Intake and output chart should be

especially lateral position provided, recorded.
and explain to the patient why position  Drugs given as per prescription.
should changed and what are the  Health education given regarding
advantages. exercise and demonstrate the method
 Nutritional assessment  Rule out the problems of the patient
 24 hours Recall assessment done  Assess the sleep and mental status of
from 7am to next day 7am the patient general condition weak and
 Health education given regarding not able to walk so, encourage for
personal hygiene--- importance of ambulation
hand washing.

Table 3: Hours Recall Method- Nutritional Assessment

Protei FAT Cal Iron
Date Time Food items Quantity Kcal CHO gm
n gm gm problem mgm
16.12.14 6 am Milk 200ml 120 6 4gm 1.3 343.6 0.8
9.30
Idly 4 nos 250 9.2 55.2 0.4 0.6 1.6
am
11 80gm150m
Ragiconji 350 9.6 112.2 0.4 4.0 2.0
Am l
EGG 1 80 5.8 0.5 5.7 30 1.0
1.30
Rice 400gm 350 9.6 112.2 0.4 4.0 2.0
pm
(100ml)
Sambar dhal 250 8.5 6 12 10.8 1.4
75gm
Rasam 50ml 7.5 0.4 1.4 0.25 0.4 0.25
G.L.Veg 50ml 7.5 0.4 1.4 0.25 0.4 0.25
Butter milk 100ml 33 1.2 1.22.5 4.0 0.45
3pm Milk 100ml 60 3 2 6.5 171.8 0.4
5pm Milk 200ml 120 6 4 13 343.6 0.8
8 pm Rice 400gm 350 9.6 112.2 0.4 4.0 0.25
Rasam 50ml 7.5 0.4 1.4 0.25 0.4 0.45
(100ml)
Sambar dhal 250 8.5 6 12 10.8 1.4
75gm
Butter milk 100ml 33 1.2 1.2 2.5 4.0 0.45
10 pm Milk 200ml 120 6 4 13 343.6 0.8
17.12.14 8am Milk 200ml 120 6 4 13 343.6 0.8
Total 2797.5 73.7 503.7 111.2 1653.2 32.2

CONCLUSION 2. Basavanthappa B.T. Medical Surgical

By this care study, I got an opportunity to Nursing. Second edition. Jaypee
provide comprehensive nursing care to my brother’s medical publishers. 2009.
client who had cerebro vascular accident. 3. Barbara. K. Timby. Introductory
It is of paramount importance for the medical surgical Nursing. London:
nurses to become competent in providing
Lippincott Williams &Wilkins. 2007.
nursing care for the patients with these
problems. More over nurse must educate 4. Carol Taylor, Carol Lillis & Pricilla
the general public to promote general Lemone. Fundamentals of Nursing.
health and family members in caring these New Delhi: Wolters Klwer Health.
patients. Private Limited. 2003.
5. Joyce. M. Black. Medical-Surgical
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Methods and Techniques 2ndedition. Missouri. 2011.

New Delhi: Vishva Prakash 10. Lippincott Williams Wilkins. Manual
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