COLLEGE OF NURSING

INSTITUTE OF LIVER AND BILIARY

SCIENCES

NURSING CARE PLAN

ON CLD-BILIARY ATRESIA

SUBMITTED TO: SUBMITTED BY:

Mrs. Madhavi Verma Pema Chukla

Reader M.Sc. (N) 2nd Year
CON, ILBS CON, ILBS

SUBMITED ON:

1
INTRODUCTION ABOUT SELF:
I Pema Chukla M.Sc. Nursing 2nd year student of ILBS Nursing College. I was posted in
TICU, Phase-I from 08-01-2024 to 19-01-2024 as a part of my clinical experience.
INTRODUCTION ABOUT CLIENT:
Baby Ishaanvi, 5 month old residence of Dwarka, Delhi. She was admitted on 14 th Jan 2024
in TICU with the diagnosis of CLD - Biliary Atresia related for liver transplant.
REASON FOR SELECTING THIS TOPIC FOR CARE NOTE:
I found my client’s case interesting and therefore, I selected chronic liver disease (CLD),
Biliary Atresia as my topic for nursing care plan. This will enable me to learn the
comprehensive care required by such patients and therefore enable me to develop and refine
my nursing care skills including the management.
INFORMANT: Patient’s mother (Himanshu) and with the help of medical records.
SOCIO DEMOGRAPHIC PROFILE
 Name: Baby Ishaanvi
 Age: 5 month
 Gender: Male
 Religion: Hindu
 Marital status: Unmarried
 Educational background: uneducated
 Occupation: unemployed
 Current Address: Dwarka, Delhi
 Date of admission: 14/01/2024
 Date of surgery : 15/01/2024
 Diagnosis: Chronic liver disease, Biliary atresia
 Surgery Living Donor Liver Transplantation left lateral lobe
graft
 Ward: TICU
 Bed number: Cubicle -2
 Treating physician: Dr. Viniyendra Pamecha

CHIEF COMPLAINTS:
Condition on admission:
Poor feeding ×1month
Irritability ×1month
HISTORY OF PRESENT ILLNESS:
Baby Ishaanvi, 5 month female has index presentation of poor oral acceptance since 1day and
irritability: crying more than usual which was acknowledged by decreased urine output since
1 day, and pale stool. He came to ILBS for further management, initially under follow up in
2
Hepatology and referred to HPB for Living Donor Liver Transplant (LDLT) and mother
came forward as a potential donor which were evaluated as per institutional protocols and
now admitted for LDLT surgery on 15/01/24. Patient had no history of fever/rash, no history
of cough, no history of vomiting, and no history of diarrhea.
PAST HEALTH HISTORY
Admitted From 01/12//23 -08/12/23 with complaints of fever and jaundice for which he went
to a local hospital where she was evaluated and diagnosed to have CLD. Also evaluated for
neonatal cholestasis –USG Liver biopsy was done and Kasai procedure was advised.
PAST SURGICAL HISTORY
Kasai procedure was done on 10/12/23.
PERSONAL HISTORY
 Diet and nutrition: Mother Breast feeding.
 Elimination patterns: Normal elimination patterns.
 Sleep pattern: Adequate.
 Activity and rest pattern: Patient only perform reflexes.
 Leisure activity: Patient do not have leisure time.
 Sexual and reproductive history: No sexual and reproductive history.
 Medication history: Patient was taking medications for jaundice on OPD basis.
 Allergic reaction: No H/O any drug allergy/ food allergy.
 Immunization: Immunized till 14th weeks.

FAMILY HISTORY
 Type of family: Nuclear
 Total no of members: 3
 Number of dependents: 2
 Family pedigree:

Mr. Tarun (65yrs) Mrs. Priyanka ( 63yrs)

Mr. Rakesh (34yrs) Mrs. Himanshu ( 32yrs)

Keys

Baby Ishaanvi (5months)

Male
Patient
Female
3
 S.no Name Relation Age/sex Education Occupation Health
Status
1 Mr. Grand Father 65 year/male Graduate Business Healthy
Tarun
2 Mrs. Grandmother 63yrs/female 12th Housewife Healthy
Priyanka standard
3. Mr. Father 34yrs/M Graduate Engineer Healthy
Rakesh
4. Mrs. Mother 30yrs/female Graduate Teacher Healthy
Himanshu
5. Baby Patient 5months/female uneducated unemployed unhealthy
Ishaanvi

Family disease: No history of DM/HTN hypothyroidism/CAD/Cancer and any psychiatric

illness in family.
PHYSICAL EXAMINATION
Date of physical assessment performed: 16/01/2024
General appearance
 Body built: Moderate
 Nourishment: Well nourished
 Level of consciousness: unconscious
 Hygiene: Maintained
 Activity: Passive range of motion
VITAL SIGNS
S.NO HR Rhythm BP RR Temp SpO2

Day-1 110b/min ST 100/50mmHg 32 98.2F 99% with

5L of O2
Day-2 114b/min ST 98/46mmHg 30 98.4F 100%
With 4L
of O2
Day-3 116b/min ST 97/42mmHg 38 98.6F 99%
With 3L
of O2

Anthropometric Measurement
 Height: 64cm
 Weight: 5.2kg

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Head to Toe Examination
Skin
 Color: Skin is yellowish
 Texture: Skin is dry
 Temperature: 98.6F
 Lesions: No macules, papules, vesicles present
 Clubbing: Not present
 Edema: No Anasarca/ No pitting Oedema
Head
 Color of hair: Black
 Shape of skull: Normal
 Scalp: Clear
 Pediculosis: No pediculosis
 Texture: Texture is soft
 Hair distribution: Less
Face
 Shape: Symmetrical, Pale
 Oedema: No facial/Ocular edema
 Hydration: Face is hydrated
 Any abnormality: No any other abnormality
Eye
 Vision: No Myopia/ diplopia/ hypermetropia
 Eyebrow: Both eye brow is in symmetrical shape
 Eye lashes: There is no evidence of eye infection
 Eye lid: Normal No sty/swelling/ptosis
 Eye ball: Eye ball is round in shape and not protruding/ Not
sunken/No exophthalmos.
 Conjunctiva: Pink/ no conjunctivitis
 Sclera: Yellow
 Cornea & Iris: Symmetrical
 Pupil: Pupil is reactive
 Lens: No opaqueness/ no crust formation
Ear
 Hearing: Patient is able to hear properly.
 External ear: Clear ear
 Tympanic membrane: There is no perforation
 Discharge: No discharge from Ear

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Nose and Sinus
 Nostrils: Nostrils are normal clean
 Nasal septal deviation: There is no septal deviation
 Discharge: No discharge is present from nose
 Any bleeding from nose: No bleeding is present
 Sinus: Sinus is normal
Mouth
 Lips: Symmetrical, dehydrated slight black in color, no
cyanosis.
 Odor of mouth: odor is absent
 Teeth: No teeth present
 Mucous membrane & gums: There is no swelling present
 Tongue: Dry
 Tonsils: No inflammation or ulceration of tonsils
Neck
 Nuchal rigidity: Not present
 Lymph node: No lymphadenopathy
 Thyroid gland: Not palpable
 Trachea: Midline
 Carotid pulse: Palpable/No distension is present
Chest:
 Scar: No scar present
 Symmetry: Symmetrical in shape
 Color: Normal skin color
 Lesion: No lesion
 Chest: Symmetrical in shape & no Barrel chest.
Axilla
 Redness: Not present
 Lumps: Absent
 Rash: Absent
 Lymph node: Not enlarged

SYSTEMATIC EXAMINATION
Neurological system
 Coordination test: Normal
 Reflexes: Normal
 Test for sensation: Normal
 GCS: 15(E4VTM6) on day 1
6

Respiratory system
 Inspection:
 Barrel chest:
 Breathing pattern:
 Palpation:
 Percussion:
Cardiovascular system
 Inspection and palpation:
 Auscultation:
 Heart rate:
 Pain:
Abdomen
 Inspection
 Auscultation
 Percussion
 Palpation
rigidity not present
15(E4V5M6) on day 2
15(E4V5M6) on day 3
Symmetrical
Absent
Normal
No tenderness
No free fluid present
Tensed and Distended
S1 and S2 normal, no murmur present
98b/m
no chest pain
: No Distension and no scars noted
: Hypoactive bowel sounds
: Dull, free fluid absent
: Soft, non-tenderness or rebound tenderness, guarding,

 Abdominal Girth : 30 cm

Genitalia & Rectum

 STD’s: Absent
 Any abnormalities: Absent
 Hemorrhoids: Absent
 Pelvic masses: Absent
 Rectal polyps: Absent
Extremities
 Movements: Voluntary movements are present
 Tremors: Absent
 Edema: Not present
 Reflexes: Not Present
 Varicose vein: Absent
 Clubbing of the fingers: Absent
 Calf muscle pain: Absent
 Homan’s sign: Negative
Spine
 Spine bifida: Absent
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  Scoliosis/kyphosis/lordosis: No scoliosis found
 Curvature: Normal
 Sacral region: No scoliosis found

INVESTIGATION
Radiological Examination
Chest X-ray
Rotation is normal
Bilateral lung Parenchyma are clear
Both hila and mediastinum appear normal
Domes of diaphragm are normal
Bony cage and soft tissue are unremarkable
USG Abdomen on 02/01/24
Impression: Chronic liver disease with findings suggestive of portal hypertension
Splenomegaly with prominent splenoportal axis and gross ascites and hepatomegaly.
Fibroscan: 75kpa (09/01/24)
CECT (30/12/23): CLD + PHTN, MPV: 3.2mm, Splenomegaly: 7.9cm, LGV: 4.3mm
S. Specimen Name of The Patients Values Normal
No Investigation Values
15/01/24 16/01/24 17/01/24 Remarks

1 Blood Hemoglobin 7.8 7.8 8.2 11 – 16 Normal

mg/dl
2 Blood Sr.Magnesium 2.4 2.5 2.5 1.7- Normal
2.8mg/dl
3 Blood Sr.Calcium 8.1 8.9 8.5 8.4- Normal
10.2mg/dl
4 Blood Sr.Bilirubin(T) 6.38 5.75 5.63 0.3- decreased
1.2mg/dl
5 Blood (D)Bilirubin 2.41 2.6 2.4 0.2mg/dl Normal

6 Blood (I)Bilirubin 1.97 2.55 2.55 0.2- Normal

0.8mg/dl
7 Blood AST 242 153.7 53.7 5-40IU/L decreased

8 Blood ALT 165 209 74.6 7-35IU/L decreased

9 Blood SAP 55 56 47 32-92IU/L Normal

10 Blood PT/INR 57.7/5.37 41.2.5/4. 25.4/2. 11.0/2-3 Normal

9 16

8
 11 Blood TLC 10.23 17.53 3.9 4- Normal
11*10~9/L
12 Blood Neutrophil 34 43.6 43.7 40-75% Increased

13 Blood Albumin 1.37 2.43 3.4 3.5- Normal

5.2mg/dl
14 Blood Sr. Sodium 142.5 142.4 136 136- Normal
145mmol/L
15 Blood Sr. Potassium 4.42 4.25 4.49 3.5- Normal
5mmol/L
16 Blood Bicarbonate - - - 23- Normal
29mmol/L
17 Blood Creatinine 0.27 0.16 0.13 0.6- Normal
1.31mg/dl

ANALYSIS
ABG
Ph-7.381 Increased (7.35-7.45) Result –abnormal
pCo2-41.1mmHg Normal (32.0-45.8)
Po2-122mmHg Normal
HCO3-24.1mmol/L Normal (18-26)
Lac-1.8mmol/L Normal (0.5-1.6)

TREATMENT
S.No. Name of Drug Frequency Dose Route
1. Inj. Elores BD 350mg IV
2. Inj. Colistin TDS 1.5mg IV
3. Inj. Metrogyl TDS 78mg IV
4 inj.Teicoplanin BD 60mg IV
5. Inj.Eraxis OD 10mg IV
6. Inj. Pantop OD 10mg IV
7. Inj. Methylprednisolone BD IV
Infusions:
1. Inj. NORAD SOS 1amp IV
2. Inj.Vasopressin SOS 4amp IV
3. Inj. Propofol SOS 1% @3ml/hr. IV
4. Inj.Albumin (5%) SOS 1/2drain IV
replacement

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TUBES AND LINES PRESENT
DEVICE SIZE SITE DATE OF DAY IN USE
INSERTION
NJ Tube 10 G Right nostril 15/01/24 D2
Central line 5 FR Right IJV 15/01/24 D2
Arterial line 22 G Right Femoral 15/01/24 D2
ET Tube 3.5mm Trachea 15/01/24 D2
Foleys catheter 06FR UB 15/01/24 D2

DRAINS
Right drain Right and left 15/01/24 D2
abdomen

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Nursing Management
Nursing Assessment
 Assess vital signs. Patient can have fever with chills, hypotension, or tachycardia.
 Review serum sodium and potassium levels, which may become depleted with nasogastric suctioning or fluid shifts.
 Review serial WBC count and differentiated to evaluate the course of action.
 Assess tissue perfusion. Note level of consciousness, skin color and temperature, pulses, and capillary refill.
 Assess hydration status: note skin turgor on inner thigh or forehead, condition of buccal membranes, and development of edema or
crackles.
 Assess the patient’s abdomen for resolution of rigidity, rebound tenderness, and distention. Auscultate bowel sounds.
Nursing Diagnosis
 Acute pain related to discomfort due to surgical procedure as evidenced by patients dull facial expression and verbalization.
 Ineffective Breathing Pattern related to decreased lung expansion, alveolar hypoventilation as evidenced by reduced vital capacity,
apnoea, cyanosis, noisy respirations, and desaturation.
 Imbalanced nutrition less than body requirement related to anorexia and dietary restrictions secondary to disease condition.
 Activity intolerance related to fatigue, lethargy and malaise secondary to disease condition.
 Risk of Injury related to disorientation and immobilization.
 Risk of infection related to invasive procedure and stasis of body fluids.
 Impaired Skin Integrity related to accumulation of drainage; altered metabolic state as evidenced by disruption of skin surface/layers and
tissues.
 Knowledge deficit related to the condition and self-care related to disease condition.

11
S.no Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
1. Ineffective Airway  The client  Assess airway patency.  Obstruction may be  Assessed the
Subjective Clearance related to will caused by the airway patency Airway was
data: could endotracheal maintain  Observe the color, accumulation of and there was cleared by
not be intubation and stasis clear, open odor, quantity, and secretions, mucous obstruction in the performing
assessed as of secretions as airways, consistency of sputum. plugs, hemorrhage, airway due to chest
patient was evidenced by as bronchospasm, accumulation of physiotherapy
unable to abnormal breath evidenced secretions and performing
speak sounds and excessive by normal  Auscultate the lungs  Thick, tenacious suctioning
secretions breath for the presence of secretions increase  The colour of the
sounds normal or adventitious airway resistance and sputum was
after breath sounds. the work of breathing yellow and it was
Objective suctioning. thick in
data: consistency.
I observed that  Monitor oxygen  Diminished lung
there are saturation prior to and sounds or the presence
abnormal lung after suctioning using of adventitious sounds  Auscultated the
sound present pulse oximetry. may indicate an lung sound there
and excessive  The client obstructed airway and was diminished
secretions will be the need for suctioning. lung sound
present free of
aspiration.
 Assess arterial blood This assessment provides
gases (ABGs). an evaluation of the  Oxygen
effectiveness of saturation
therapy. monitored prior
to suctioning and
hyperventilated
the patient before
 Signs of respiratory suctioning
 Note excessive compromise include
coughing, increased decreasing PaO2 and  Arterial blood
dyspnea, high-pressure increasing PaC analysis done
alarm on the bipap, and  The intubated client twice a day
visible often has an ineffective through arterial
12
 cough reflex, or the line
 Explain the suctioning client may have a
procedure to the client; neuromuscular or
give reassurance neurosensory
throughout the impairment, altering the
procedure. ability to cough.

Secretion clearance in
 Turn the client in every clients with artificial  There were
two hours. airways is mainly visible secretions
performed through on the mouth of
 Administer mouth the patient
intravenous therapy  Turning mobilizes
and aerosol secretions and helps
bronchodilators as prevent ventilator-
indicated. associated pneumonia.
This promotes the  Before
drainage of secretions suctioning
and ventilation to all explained the
lung segments, thereby procedure to the
reducing atelectasis. patient and
 Consult a respiratory meanwhile
therapist for chest  The frequency of performing
physiotherapy as suctioning should be procedure talked
indicated. based on the client’s with the patient
clinical status, not on a
preset routine such as  Provided position
every two hours. to the patient
every second
 Hyperoxygenation hourly
before, during, and after
endotracheal suctioning
decreases hypoxia and
cardiac dysrhythmias
13
 related to the suctioning
procedure.

 Maintaining hydration
increases ciliary action  Hyperoxygenated
to remove secretions and the patient before
reduces the viscosity of suctioning
secretions.

 Chest physiotherapy
includes the techniques  Nebulization with
of postural drainage and ipravent, calistin
chest percussion to and ambroxol
loosen and mobilize given to the
secretions. This patient
promotes ventilation of
all lung segments and
aids in the drainage of
secretions.
 Assisted in
performing chest
physiotherapy
with
physiotherapist

S.no Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation

14
2. Imbalanced  The client  Weigh the client  The client with a  Weight can’t be
Subjective Nutrition: Less will maintain regularly. endotracheal tube assessed as client
data: could than Body a balanced may be able to eat, was completely bed
not be assessed Requirements nutritional but a client with an ridden
as patient was related to less status and ET tube must be tube
unable to oral intake from input output  Evaluate the client’s fed or parenterally  The patient was on
speak mouth as will be well ability to eat. nourished. Nutrition mechanical ventilator
evidenced by maintained status is the best and ET Tube was After 6 hours
input output predictor of placed so the patientof nursing care
chart mechanical ventilator was given feed the total intake
Objective duration for critical through ryles tube. of the patient
data: clients was 550 ml,
I observed that which was
the intake of more than the
the patient is  A functioning GI output of the
lower than the  Abdominal girth was patient
system is essential for 22 cm and ascites
output the proper utilization was present. The
of enteral feedings. patient is suffering
Mechanically from diarrhea.
ventilated clients are
at risk of developing
 Auscultate for bowel abdominal distention
sounds and measure due to trapped air or
abdominal girth. ileus and gastric
Observe for diarrhea bleeding caused by
and constipation. stress ulcers.

 If the client is  Monitored gastric

 Monitor gastric
residual volumes.
15
administered with residual volumes.
enteral feedings,
gastric residual
volumes should be
monitored to avoid
gastric distention and
an increased risk of
 regurgitation.

 This prevents
dehydration that can  As the dietician has After 6 hours
be exacerbated by advised the patient of nursing
increased insensible was given liquid diet intervention, all
losses (ventilator or was advised like rose the diet ordered
 Encourage increased intubation) and water, lassi, milk , by the dietician
liquid intake of at reduces the risk of coconut water. was
least 2000 mL per constipation. appropriately
day or as tolerated given to the
within cardiac limits.  These methods patient
provide adequate
nutrients to meet
individual needs
when oral intake is
 Administer early insufficient or
enteral feedings as inappropriate.
needed.

S.n Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation

o
3. Subjective Risk of  The health  Identify risk factors  Intubation interferes  Endotracheal
data: could infection related care workers for the occurrence of with the normal intubation can be
not be assessed to endotracheal as well as infection. defense mechanism identified as the risk
as patient was intubation and family that keeps factors for the
unable to disease members microorganisms out of occurrence of
speak condition will learn the lungs. ET tubes, infection
interventions especially cuffed
to prevent or ones, interfere with
the mucociliary
reduce the
transport system that
16
 Objective risk of
data: infection.
I observed that
the patient is at  Assess the  Yellow or green
risk of characteristics of the
infection client’s sputum.
 Auscultate breath  The presence of
sounds.
 VAPs occur in up to
 Assess for the signs of
pulmonary infection
including increased
temperature, purulent
secretions, elevated
white blood cell
count, positive
bacterial cultures, and
evidence of
pulmonary infection
on chest X-ray
17
helps clear airway
secretions.
After 6 hours
purulent odorous  Assessed the sputum of nursing care
sputum is indicative and it was thick in the riskfor
of infection; thick, consistency and infection was
tenacious sputum yellow in colour reduced to
suggests dehydration. some extent :
Proper hand
hygiene was
 Wheezing sound done , ET
rhonchi and wheezes present on suctioning was
suggests retained auscultation done through
secretions requiring proper closed
expectoration or channel, no of
suctioning. Assessing visitors were
and reporting early limited
indicators of infection
will enable prompt
intervention and
treatment.
28% of clients on  Assessed for the sign
ventilators. Mortality of infection but none
rates of 40% to 50% were present
have been reported for
these clients. Most
ventilator-associated
infections are caused
by bacterial
pathogens, with gram-
negative bacilli being
common.
 studies.

 An artificial airway
 Encourage the family
members, and other
staff members to
engage in proper hand
hygiene.
bypasses the normal  Proper hand hygiene
protective was performed by the
mechanisms of the health care provider
upper airways. before touching the
Promote proper hand patient and its
hygiene by hand environment or
washing or alcohol- before performing
based hand rubs, and any procedure
wear the appropriate
PPE when handling
respiratory secretions
and contaminated
equipment.

 Oral hygiene reduces

 Provide oral hygiene oral bacterial flora,  Oral hygiene was
twice daily , including which could be performed one time
the use of a dental oral aspirated. in the morning and
antibiotic rinse. one time in the
evening
 The client is already
 Limit visitors and compromised and is at
avoid contact with increased risk for  Only one attentand is
persons with exposure to infections. allowed to meet the
respiratory infections. patient that to with
proper precaution
such as wearing full
PPE and hand
hygiene
 Keep the head of the  Elevation promotes
bed elevated to 30 to better lung expansion.
45 degrees It also reduces gastric  Head to the bed was
18
 reflux and aspiration. elevated to 45 degree

 This technique
 Use sterile suctioning
decreases the
procedures and reduce  Proper closed
introduction of
the number of times suctioning was
microorganisms into
the ventilator tubes performed to
the airway.
are open. maintain sterility

19
 PROGRESS NOTES
19/01/24
 Hand over taken under senior staff supervision.
 Patient was on mechanical ventilator
 Checked the patient all iv lines and its patency and they
were all patent. Central line was present left jugular vein
and arterial line was present on right hand
 Closely monitoring of vital signs and document every 1
hourly in the ICU chart.
 Closely monitored the intake and output and document in
the ICU chart.
 Feed was given through ryles tube as per the order of
dietician
 Given morning (10 am) medication to the patient .
 Nebulization was given to the patient and then suctioning
was done using closed suctioning technique.
 Hygiene of the patient well maintained.
 Provided back care to the patient and check for pressure
ulcer and applied coconut oil.
 ABG was done at 10:30 am and 12:30 pm and documented
in the ICU Chart.
 Followed all advice as per doctor after the doctor round.
 Medication administration done as per the orders by
doctor.
 Proper aseptic technique was used while performing all
the procedures
 Given hand over to the evening staff.
20
20/01/24
 Hand over taken under senior staff supervision.
 Patient was on mechanical ventilator
 Checked the patient all iv lines and its patency and they were all patent. Central
line was present left jugular vein and arterial line was present on right hand
 Checked for abdominal girth
 Closely monitoring of vital signs and document every 1 hourly in the ICU chart.
 Closely monitored the intake and output and document in the ICU chart.
 Feed was given through ryles tube as per the order of dietician
 Given morning (10 am) medication to the patient.
 Nebulization was given to the patient and then suctioning was done using closed
suctioning technique.
 Assisted the physiotherapist while doing physiotherapy
 Hygiene of the patient well maintained.
 Provided back care to the patient and check for pressure ulcer and applied
coconut oil.
 Every second hourly position change
 ABG was done at 10:30 am and 12:30 pm and documented in the ICU Chart.
 Followed all advice as per doctor after the doctor round.
 Medication administration done as per the orders by doctor.
 Proper aseptic technique was used while performing all the procedures
 Given hand over to the evening staff.
 SUMMARY
In this nursing care plan, I have taken the topic Biliary Atresia. My patient baby Ishaanvi, a 5
month old was apparently well 1 month back when she developed jaundice which was
insidious onset, progressively increasing associated with dark colour urine and pigmented
stools. There was no history of fever, hematemesis, melena, pain in abdomen at that time.
Baby was diagnosed with CLD biliary atresia She was then worked up for liver donor liver
transplant and her mother came forward as voluntary live liver donor. After all the test of the
donor as well as the receiver was done, on 19 january 2024 the liver transplant was done.

BIBLIOGRAPHY:
1) Lippincott, manual of nursing practice, edition 8th publisher Jaypee brothers Pp.
1075-1077.
2) Brunner &Suddarth’s, Medical Surgical Nursing. 10th Edition: Pp-1113-1116.
3) PubMed:http://www.pubmed.org
4) Joyce M. black, eighth edition, volume 2, Medical surgical nursing.

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