TUBERCULOSIS

 

TUBERCULOSIS

 

INTRODUCTION

Tuberculosis (TB) is a major and growing public health problem in Zambia. The Tubercle Bacillus bacteria cause it, which forms lesions called tubercles. The Tubercle bacilli remain dormant in lesions and persist for many years. It involves and sometimes produces growth, lesions in other organs and tissues.

We will therefore give a detailed accounts of the risk factor, pathophysiology. Clinical manifestations, management and preventions of Tuberculosis

 

OBJECTIVES

At the end of the discussion, participants should be able to:

1. Define Tuberculosis
2. State the cause and risk factors of TB
3. Describe the Pathophysiology of TB
4. Explain the clinical manifestations of TB
5. Describe the management of TB i.e. investigations, medical and surgical management.
6. State client education guide for TB

 

DEFINITIONS

TUBERCULOSIS is a communicable, infectious, inflammatory and chronic disease that can affect any part of the body

 

Pulmonary Tuberculosis (P.T.B) is a chronic infectious disease that is characterized by the formation of granulomas in the lungs.

 

Extra Pulmonary Tuberculosis is T.B occurring anywhere outside the lungs e.g. TB abdomen. TB spine, TB meningitis

 

Miliary Tuberculosis is widespread dissemination of TB throughout the body.

 

EPIDEMIOLOGY

Despite improved methods of detection and treatment, TB remains a worldwide health problem with an estimated 3 million diagnosed each year (Polaski&Tatro, 1996). In Zambia, TB accounts for 1 out of every 6 adult deaths in Zambian Hospitals.  One third or more of Zambians carry the TB bacteria in their bodies.  As many as one hundred thousand Zambian have active TB. The number of cases of TB reported every year has tripled in the last 10 -15 years largely as a result of the HIV epidemic (CHoH, 1997).  TB was declared a national emergency by the Ministry of Health in 1997

 

            RISK FACTORS

1.   Occupation; health workers are at risk of contracting TB due to their nature of

     work.Those who work in industries; for example, miming industry.

2.   The social –economically disadvantaged people often have a high incidence of TB which may be as a result of poor nutrition, poor housing, inability to access medical services etc

3.   The undernourished persons are more prone to contracting TB People living in overcrowded and poorly ventilated houses are predisposed to TB infection.

4.   Alcoholism clients dependent on alcohol or other chemicals because of malnutrition, debilitation and generally poor health.

5.   Age ,elderly, infants and children under the age of 5 years

     Clients with reduced immunity e.g. HIV infection, malnutrition, on cancer therapy or on steroid therapy

 

AETIOLOGY

TB is an infectious disease caused by the bacillus mycobacterium tuberculosis or the tubercle bacillus, an acid fast aerobic organism. It is spread by droplet or ingestion. Mycobacterium Bovis does cause TB in humans also.

 

PATHOPHYSIOLOGY (Anderson J.R.1985)

It incites a distinctive chronic inflammatory response called granulomatous inflammation. When a susceptible person inhales mycobacterium tuberculosis, he may become infected.

 

Primary Infection TB

Infection of an individual who has not been previously infected or immunized with TB bacilli gives rise to the primary lesion ( Ghon Focus) at portal of entry in the  lung, tonsil or small intestine. This usually remains small and commonly heals without becoming detectable .Although a primary infection may be only microscopic in size , the following sequence of events typically occurs.

 

Many of the infecting mycobacterium TB are phagocytosed by wondering macrophages (at the site of infection) without bringing about destruction. The macrophages aggregate in increasing numbers to form a macrophage granuloma or nodule. Eventually macrophages enlarge and change to epithelioid cells. However before development of hypersensitivity and cell –mediated immunity, many of the bacilli that survive within the macrophages are carried into regional lymph nodes at the hilum of the lungs, in the neck or mesentery depending on the site of the primary lesion. The combination of the primary lesion and enlarged caseous regional lymph nodes is called Primary focus. The lymphocytes surround the macrophage granuloma after 10 days of infection and this is termed a tubercle. Lymphocytic infiltration to the infection site follows develop cell mediated immune response, which appears in the form of sensitized T cells and is detectable as long as living bacilli remain in the body (perhaps for life).The acquired immunity usually inhibits further growth of bacilli and development of active infection. Most primary tubercles heal over a period of months through the formation of fibrous scars and ultimately calcified lesions. These lesions may contain living bacilli that can reactivate (even after many years) when the immunity is lowered to cause re-infection or secondary TB. A primary lesion may not undergo a process of necrotic degeneration cessation) which produce cavities filled with cheese like mass of tubercle bacilli, dead white blood cells and necrotic lung tissue.

 

Primary TB infection may be controlled, in this situation, the primary complex sites progress and worsen, possibly causing cavitations and spread of active infection, the client becomes clinically ill.

 

Secondary or Re-infection TB

In addition to progressive primary disease. Re-infection may also lead to a clinical form of active TB. Primary sites of infection containing TB bacilli may remain latent for years and then reactivate if the client’s resistance is lowered. The re-infection lesion is usually in the apex of one or the other lung and may extend to give a large local lesion with one or more cavities. There may be involvement of the local lymph nodes.

 

 

SUMMARY OF PATHOPHYSIOLOGY

 

In halation of bacilli

 

Implantation in bronchiole or alveolus

 

Phagocytosis and lympocytosis occur

 

Macrophages surround and engulf bacilli

 

Ghon’s focus (granulomatous lesion)

 

Soft caseous necrosis of central part of Ghon’s focus –cheese like

 

(Tuberculin test is positive due to cell mediated hypersensitivity immune response)

 

Bacilli to tracheobronchial lymph nodes through lymph channels causing granulomas in

tracheobronchial lymph nodes

 

Scar tissues forms and encapsulates primary lesion (where there is small number of

Organisms and adequate body resistance).

 

Calcified lesion (healed primary lesion)

 

Secondary TB (in lowered immunity or reinfection)

Activation of healed primary lesion

 

Extensive destruction of lung

tissue (granulomatous tissue)

 

Bronchus                                 Air filled cavity                      blood & lymph vessel

Purulent Sputum                     Bronchogenic spread              Hematogenic dissemination

                                        (Aspiration of infected material)

           

Clinical manifestations

1. Cough – The dry cough is initially due to the irritation by the bacilli that is foreign to the system. Later becomes productive when the cheesy material spills into the bronchus and coughed up, usually purulent sputum. Later there is hemoptysis due to erosion of blood vessels
2. Chest pain – is due to the destruction of tissue by disease process exposing the nerve endings and also due to a reduction of oxygen causing ischemia leading to pain. Pain is dull or pleuritic in nature, chest pain, and tightness may be present.
3. Dyspnoea– is due to a reduction in lung surface area, the destruction of blood vessels, infection and inflammation of alveoli. If this persists and becomes severe there may be cyanosis.
4. Fever – is due to the stimulation of the temperature – regulation center in the hypothalamus by the toxins of the bacilli. Fever is cyclic, present around mid-day and in the night. Fever is long term and low grade.
5. Chills and Sweat – are due to fever, there may be sweat around mid-day and at night when there is fever.
6. Fatigue and anorexia – due to massive destruction of tissue by bacilli and a high ATP requirement. Prolonged anorexia leads to weight loss.

 

MANAGEMENT

 

HISTORY TAKING

Throughout health history interview, record the following data about a symptom problem:

¨       Onset (Specific data, sudden or gradual)

¨       Duration

¨       Frequency

¨       Precipitating factors

¨       Aggravating or alleviating factors

¨       Treatment received or self care given

¨       Outcome

 

Present Health Status

¨       Allergies

¨       Tobacco use

¨       Medications

¨       Aerosols or inhalants use

¨       Recent screening or diagnostic assessments

¨       Nutritional data e.g. sudden weight loss, obesity.

 

Present illness

¨       Cough – Type, onset, duration, pattern, severity and associated symptoms

¨       Sputum production- amount, color, presence of blood, odor, consistency and pattern of production.

¨       Dyspnoea

¨       Chest pain

¨       Fever

 

Past health History

¨       Respiratory infections and diseases

¨       Trauma to respiratory system

¨       Surgery to respiratory system

¨       Chronic conditions of other systems e.g. renal or cardiac diseases

 

Family Health History

¨       Tuberculosis, emphysema, lung cancer, pleural effusion, allergies

 

Other Considerations

Employment history to determine exposure to chemicals, vapors, and dust allergens animals.

 

PREPARATION FOR EXAMINATION: CLIENT AND ENVIROMENT

-        Warm, well lit, quite room, supplementary lighting is essential for close

Inspection of specific areas

-        Privacy

-        Teach patient how to sit and breath during auscultation of posterior thorax

 

 PHYSICAL EXAMINATION

 Inspection

¨          Measure and assess pattern of breathing

¨          Assess the skin and overall configuration,  symmetry and integrity of thorax

¨          Inspection of nails and lips for color and clubbing

 

Palpation

¨          Further assess abnormalities suggested by health history or observation e.g. tenderness, masses.

¨          Assess skin and subcutaneous structures

¨          Assess thoracic expansion

¨          Assess tracheal  position

¨          Assess lymph nodes for lymphadenopathy

 

Percussion

Ø  Determine the relative amounts of air, liquid or solid materials in the underlying lung.

Ø  Determine the positions and boundaries of organs. There is dullness or stony dullness on affected parts.

 

Auscultation

Obtain information about the functioning of the respiratory system and about presence of obstruction in the passages. There is bronchial breathing, reduced air entry and crepitation

 

INVESTIGATIONS AND DIAGNOSIS

1. History of exposure to TB and presenting symptoms.
2. Skin testing with either tuberculin – purified protein derivative (PPD) old tuberculin (OT) is most common. The primary purpose is to detect individuals who are infected but not necessarily diseased. Used as s screening device, can provide false positive and false negative results. Mantoux test used for diagnosis and jet gun/ multiple puncture for screening.
3. Chest x-ray –posterioanterior (PA ) and lateral are the standard views. They will show cavities in the lungs.
4. Sputum smear –Acid Alcohol fast bacilli –determine the presence of mycobacterium tuberculosis, which after taking up dye is not decolorized by acid alcohol.
5. Sputum culture and sensitivity –culture identifies the specific organism to enable making a specific diagnosis. It should be collected before initiation of antibiotic therapy and thereafter to monitor effectiveness of antibiotic therapy. Sensitivity serves as a guide to anti- microbial therapy by identifying antibiotics that prevent the growth of the organism present in the sputum.
6. Gastric washing –most patients swallow sputum when coughing in the morning or during sleep, an examination of gastric content can reveal causative organism.
7. Cerebral Spinal fluid or aspirates from abscess analysis show the TB bacilli.
8. Blood – FBC, there is raised white cell count. ESR is raised. It is above 20mm

 

DIFFERENTIAL DIAGNOSIS

1. Pneumonia
2. Lung cancer
3. Lung Abscess
4. Cardiac disease
5. Pneumoniocosis

 

MEDICAL TREATMENT

It is divided into three categories

 

Category 1

¨     Very infectious group

¨     New patients who are smear positive

¨     Patients with TB meningitis ,TB spine , military TB

¨     They are put on short course therapy of 2 months intensive supervised treatment

Then 6 months continuation phase.

¨     Drugs 2EHRZ/6EH

Ethambutol 800mg OD

Rifina 450/300 mg OD

Pyrazinamide 1.5 gm OD

In TB meningitis, continuation phase is up to 10 months. After initial intensive phase, sputum is tested, if it is positive again, intensive phase continues for 1 more month.

 

Category 2

¨     Relapses

¨     Patients who were initially smear positive and remained positive after 5 -8 months

of treatment (usually due to drug resistance).

¨     They are put on treatment therapy of 3 months intensive therapy and 5 months

Continuation phase

¨     Drugs 2HRZS/1HRZE/5HRE

 

Category 3

¨     Children below 12 years

¨     Pulmonary smear negative but extra pulmonary smear positive

¨     Pleural effusion

¨     Drugs

Children 2RHZ/4HR (ethambutol not given as it may cause blindness)

Adult 2RHZ/6HE

Pregnant women 8HRZE

 

DRUGS

ISONIAZID (INH)

Classification                          Bactericidal, penetrates all body tissues including CSF

Dosage                                                15mg/kg po or im

Side effects                             Peripheral neuritis, hepatitis, fever, hypersensitivity (rash)

Comments/ interventions       Daily alcohol intake interferes with metabolism in INH and increase risk of hepatitis; antacids containing aluminum interfere with absorption of INH.

RIFAMPICIN (RIF)

Classification                          Bactericidal, penetrates all body tissues including CSF

Dosage                                                600mg po

Side effects                             Hepatitis, febrile reactions, thrombocytopenia (rare) and hepatotoxicty increase when given with INH

Comments / interventions      Urine, sweat tears may turn orange temporaliy, decrease effectiveness of oral contraceptives, anticoagulants, corticosteroids, barbiturates hypoglycemic and digitalis.

 

ETHAMBUTOL (EMB)

Classification                          Bacteriostatic does not penetrate CSF, penetrate other body fluids

Dosage                                                50mg/kg po

Side effect                               optic neuritis, (reversible with discontinuation of drug) skin rash

Comments / interventions      no significant reaction with other drugs, check vision monthly; give with food.

PYRAZINAMIDE (PZA)

Classification                          Bacteriostatic or bactericidal, depending on susceptibility of mycobacterium

Dosage                                                50mg /kg up to 3.5 g po

Side effect                              hyperuricemia, hepatitis, arthraglia, G.I irritation

Comments /interventions       Obtain baseline liver function tests and repeat regularly give with food; drink 2L of fluid daily.

 

STREPTOMYCIN (SM)

Classification                          Bactericidal, amino glycoside, disrupt proteins synthesis, poor penetration into body tissues including CSF

Dosage                                                25-30 mg/kg im

Side effect                              8^th cranial nerve damage (vestibular or ocular), damage often irreversible nephrotoxicity.

Comments/ interventions        Monitor kidney and vestibular function monthly monitor hearing

 

PROBLEM ANALYSIS

1. Maintenance of a safe environment ( Biological , Physical, Psychological Environment

¨     Risk of injury from falls due to fatigue

¨     TB association with HIV/AIDS may lead to depression

2. Communication

¨     Voice changes and difficult in speaking due to dyspnoea

¨     Anxiety due to unfamiliar place and stigma, may lead to isolation.

¨     Fear of prognosis may lead to quick temper and sharp answers

¨     Depression may flatten voice to monotony

3. Breathing

¨     May have rapid respiration and pulse due anxiety

¨     May have difficult in breathing due to a reduction to lung tissue

¨     May need oxygen to relieve dyspnoea

¨     Needs to be nursed more in upright position to promote ventilation

4. Eating and Drinking

¨     Needs plenty of fluid, warm liquids, semi-solid foods and fruits to loosen

Secretions

¨     Months washed to stimulate appetite

¨     Frequent emptying and covering of sputum mug which is put away during

Meal times to promote appetite

¨     Needs small frequent nutrition meals, high in protein, carbohydrate, iron

And vitamin to promote appetite and boost ability to fight infection.

5. Elimination

¨     Needs plenty of fluid , warm liquids, semi –solid foods and fruits helps

Prevent constipation

¨     Needs a sputum mug and teaching on how to care for the mug and on

Collection of sputum specimen

¨     Inform the patient of the stool and urine Colour changes to avoid anxiety

¨     Frequent change of clothes and beddings due to excessive sweating

6. Personal Cleansing and Dressing

¨     Dressing pattern may change according to fever , hence dressing may not

Be commensurate with whether at times which may reduce self esteem

¨     Needs to understand the importance of care of sputum mug coverage

Mouth when coughing

¨     Frequent change of clothes and linen due to sweating

¨     Needs to have his / her beds tidy without creases to prevent bed sores

7. Controlling Body Temperature

¨     Patient may have fever especially afternoon and night due to infection by

Bacilli.

¨     Temperature to be monitored regularly (4 Hourly) to detect fever pattern especially in acute phase

¨     Clothing and beddings should be suitable for the body temperature which varies from time to time

¨     Increased metabolic rate due to fever may raise the temperature

8. Mobilizing

¨     Drowsiness from length periods of lying in bed would prevent him /her to mobilize

¨     Lack of energy and fatigue from over use of ATP will lead to long rest

Periods preventing mobility

9. Work and play

¨     Convalescence for several days leads to inability to cope with usual work schedule

¨     Need for divisional therapy (music. Imagery , reading watching TV) to prevent loneliness and boredom and divert mind from the stigma of the disease

¨     Allow family and friends to visit if possible and encourage the patient so that he has adequate play time

10. Expressing Sexuality

¨     Lack of privacy may lead to frustration

¨     Loss of identity due to hospital environment

11. Sleep and Rest

¨     Lack of sleep due to anxiety , strange environment dyspnoea

¨     Lack of sleep due to chest pain and fever

¨     Noise and excessive working hours may affect his or her rest sleep

 

 

12. Dying

¨     Needs information (parents) on disease process and prognosis to relieve fear of death

¨     Discussion of life after death and spiritual support with family and patients is important tom prepare family and patients

¨     May involve others who recovered from the disease to share experiences with patients to give hope of recovery

 

NURSING CARE PLAN

The nursing care will be dependent on the problem identified. These are those based on the 12 activities of living and the presenting sings and symptoms. Also considering the general condition of the patient

 

Problem One - Altered gas exchange

Nursing Diagnosis

Gas exchange impaired related to decreased lung surface area evidenced by dyspnoea and fatigue

 

Client Goal

The client will have improved gas exchange as evidenced by vital signs within normal limits for client’s age and condition (adult, respirations 18 -24; pulse 80.100; BP systolic 100-120 diastolic 70-90 Temperature 35.5-37.2 degrees Celsius) , pink skin and mucous membranes, decreased dyspnoea and arterial gases within normal within two weeks

 

Nursing Strategies

Encourage nutritious food (high protein, carbohydrates, and vitamins) and fluid intakes; encourage frequent mouth washed, small frequent meals, well balanced and client’s preferences. Monitor weight daily .Monitor temperature every six hours.

Give antipyretics and Anti Tuberculosis Drugs

 

Client outcome

Client has a reduction of anorexia and fever and thereby exhibits an improvement in nutritional intake with weight gain of 3Kg and a temperature of 36 to 37.2 degrees Celsius within two weeks.

 

Problem Two - Knowledge Deficit

Nursing Diagnosis

Knowledge deficit about spread and treatment of TB related to lack exposure to information a evidenced by anxiety.

 

Client Goal

Client will be knowledgeable about spread and treatment of TB related to lack of exposure to information as evidenced by inability to correctly answer question on spread and treatment of TB (names of medication being received and schedule for taking them and naming expected side effects of medications) within one week.

 

Nursing Strategies

Nurse builds a trusting relationship so that client’s education is an on going process and behavioral changes are made. All details of the disease and drug therapy are carefully explained. Encourage client to ask question,, reassure them, and explain also to family members .Let patients doing well on TB treatment discuss condition and treatment  with the patient.

 

Clients Outcome

Client acquire knowledge and understanding of tuberculosis evidenced by answering questions about spread and treatment (Names of medication being received and schedule For taking them and naming expected side effects of medications )of TB correctly within one week.

 

Problem Three - Fear

Nursing Diagnosis

Fear relation to long-term illness requiring long-term chemotherapy, life style changes unit less infectious as evidenced by withdrawal

 

Client Goal

Client will accept and adjust to long term illness requiring long term chemotherapy, life style changes until less infectious as evidenced by social interaction with family , friends and staff and explaining the importance of long term chemotherapy and life style changes within one week.

 

Nursing Strategies

Explain disease process to the client and signification others, the necessity of long term therapy and changes of life style until less infectious. Explain treatment and investigations encourage questions, and build therapeutic relationship with client. Encourage supportive therapy from the religious minister, social worker, and counselor to reinforce and assist with changes in life style. Give divisional therapy (music, imagery)

 

Client Outcome

Client has accepted and adjusted to long term illness requiring long term chemotherapy life style changes until less infectious as evidenced by social interaction with family , friends and staff and explaining the importance of long term chemotherapy  and life style changes within one week.

 

Problem Four – High risk for infection

Nursing Diagnosis

High risk for spread of infection related to denial and stigma of TB evidenced by un protected cough

 

Client Goal

Client will prevent and minimize spread of infection related to denial and stigma of TB evidenced by continuation of medication therapy , covering mouth and nose while coughing, using and disposing tissues correctly  (trying in plastic and throwing in covered bins ) when coughing and sneezing , and encouraging close contacts to report for examination within two days.

 

Nursing Strategies

Explain mode of infection spread, importance of medication therapy, use and disposal of tissues after cough or sneeze, importance of contact tracing, nutritional diet, good hygiene, ventilation and avoidance of overcrowding. Monitor vital signs and record, monitor signs of infection spread.

Clients Outcome

The client prevent and minimizes spread of infection as evidenced by continuation of medication therapy, covering mouth and nose while coughing using and disposing tissues correctly (trying in plastic and throwing in covered bins) when coughing and sneezing, and encouraging close contacts to report for examinations

           

COMPLICATIONS

1. Miliary TB –due to large numbers of bacteria entering the blood and giving rise to scattered tubercles in the various organs of the body.
2. Respiratory failure - due to extensive scaring of the lung tissue and accumulation secretions in the airway.
3. Pleurisy with Effusion
4. Broncho pleural fistula
5. Empyema
6. Atelectasis
7. Pneumothorax

 

CLIENT EDUCATION GUIDE

Teach the client as follows :

¨     TB is infectious ,but it may be cured or arrested if you take your medication as

prescribed.

¨     TB is transmitted by droplet infection and is not carried on articles such as

clothing, books or eating utensils. You do not dispose of any possessions

¨     Cover your nose and mouth when coughing, laughing or sneezing                                 

¨     Wash your hands very carefully after any contact with body substance masks or soiled tissues. Sputum is highly contaminated. Cough into tissues paper and dispose of them properly

¨     Wear masks inn appropriate situations when advised. Make sure they are tight fitting and changes them frequently.

¨     People with TB are usually not restricted in their activities for more than 2 to 4  

      weeks after medications is begun and they are not isolated from others as long as compliance is maintained. TB is no longer treated by isolation in sanatoriums.

¨     Treatment may be necessary for long time. Take your medication exactly as

prescribed and report all side effects to your doctor. Do not stop the medication for any reason without the doctor’s supervision. Keep an adequate supply of medication available at times to avoid running out. Compliance with treatment is essential. (Luckman. 1993)

 

 

 

 

CONCLUSION

Tuberculosis is one of the major communicable diseases and it is a worldwide problem. However with good preventive, diagnostic and curative measures it can be controlled and is curable.

Transmission is person to person by air therefore confined spaces and poor ventilation increase the risk of exposure. Once infected, a person can be infected for life and can develop active TB disease at any time. HIV infection facilitates progression on the active TB disease, and treatment is essentially the same regardless of HIV station for the affected individual and the community. It is essential that TB treatment are taken properly and completed.

Tuberculosis is curable, provided that treatment is began early and the patient takes all the prescribed drugs as per regime, If untreated, about 50% of TB patients will die within two years

 

Control of TB and Health Education

Ø  Treat new cases promptly, before the disease spreads to others.

Ø  All family members and close contacts should be checked.  Children under five with positive Heaf tests should be given INH prophylactically.

Ø  Work to improve social conditions which increase the risk of becoming infected, eg. overcrowding, poverty, malnutrition.

Ø  Educate patients as to the importance of covering the mouth when coughing, proper disposal of sputa by burying or burning, and the necessity of finishing the course of treatment.  Educate the public regarding spread and control of the disease.

Ø   Vaccination with BCG.  This is a suspension of TB bacilli which will not cause disease but will cause the recipient to produce antibodies.  In Zambia BCG vaccine is given to new born babies, school entrants and school leavers.

Ø  Eliminate TB in dairy herds by TB testing and slaughter if reactive; pasteurize or boil milk.

Ø  Educate the public regarding the spread of AIDS, which lowers immunity and increases the risk of TB.

Ø  Tuberculosis registry.  TB is a notifiable disease and the names of all patients are reported to the Health Department.  They are given a card indicating the type and duration of treatment.  They are to return to the clinic until the disease is considered inactive.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Anderson .J.R (1985) Muir’s Textbook of Pathology. Butler and Tanner

Limited London

 

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Health and physical Assessment  St Louis: Mosby

 

Black ,J.M &Matassarin –Jacobs ,E, (1993).Luckmann and Sorensen’s

 

Medical surgical nursinga psycho logic approach 4^th Ed. Philadelphia W.B Saunders Company.

           

CBoH (1997) Integrated Technical Guidelines for front line health workers. Lusaka

 

Dudas,S, Beyer’s M (1977). The Clinical practice of medical –surgical

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Ignatavicius, D.D workman, L.M &Mishler,M.A (1999) MedicalSurgical Nursing Across the health care continuum.3^rdEd: Philadelphia W.B Saunders Company

 

Phipps,W.JLassmeyers, V.L Sands J.K & Lehman M.K (1995) MedicalSurgical Nursing, Concept and clinical practice 5^th Ed St Louis Mosby.

 

Smeltzer, S.Bare B (1992) Brunner and suddarth’s textbook of medical –Surgical Nursing 7^th Ed Philadelphia: J.B Lippincott Company