CASE STUDY

ON
CHOLELITHIASIS

SUBMITTED TO: SUBMITTED BY:

Mrs Jhunilata Pradhan (mam) Ram Ninad Pattnaik

Assistant prof Msc nursing 2nd yr

Sum Nursing college Sum Nursing college

SUBMITTED ON:
 IDENTIFICATION DATA

Client’s name : Mrs. Soudamini Bisoi

Age : 45 years
Sex : Female
IP No : 893742115
Date of admission : 10/12/2023
Ward :7
Bed no. : 04
Education : Graduation
Occupation : Housewife
Marital status : Married
Religion : Hinduism
Address : At/po- Jagatsinghpur, Dist: - Chatra
Provisional diagnosis : Cholelithiasis, Hypothyroidism

I. Presenting Chief Complaints:

The patient complaints for –
 Abdominal pain since 1month (Abdominal pain was aggravated from 7 days)
 Spread below the right shoulder or to the back abdominal
 Nausea

II. History of Present Illness

Mrs. Soudamini Bisoi came to Gastro OPD, IMS & SUM Hospital due to abdominal pain and
Nausea on date (10/12/2023) after checkup in OPD my patient was admitted to Ward-7at 01: 10pm.
III. Past medical history
Mrs. Soudamini Bisoi is having Hypothyroidism and taking Tab. Thyroxine 75mg
IV. Past surgical History
Mrs. Soudamini Bisoi doesn’t have any past surgical history.
V. Family History
 Mrs. Soudamini Bisoi family members have significant history of Gall stone disease.

VI. Family characteristics-

Mrs. Soudamini Bisoi lives in nuclear family.

S. Name of the Relationship Age Educationa Occupation Health Status Age &
No. family members with the (yr.) / l Status mode of
Patient Sex death
1 Mr. Trilochan Husband 52yr/M Graduation Businessman Not significant -
Bisoi
2 Mr. Sourav Bisoi Son 20 yr/M Engineerin Student Healthy -
g

3 Mr. Subham Son 16yr/M 12th Student Not significant -

Bisoi

III. Socioeconomic history:

 My patient is the second head of the family.
 She belongs to a middleclass family.
 She is housewife.
 Electricity and water facilities are available in house.
 Drainage facility is proper.
 Income per month: The monthly income is approx. 50,000/-.
 Expenditure : approx.: 30,000 /- rupees
 Recreational facilities : Present
 Medical facilities : Available
IV. Personal History
 Habits & hobbies: Her habits is drink lots of water throughout the day.
Her hobbies is spending time in Agriculture.
 Elimination pattern:
 Bladder elimination:-Self voiding
 Bowel elimination:- He passed stool since admission
 Sleeping pattern: Sleeping pattern is good 8hrs per day
 Nutritional history :
Vegetarian / non-vegetarian: Non-vegetarian
 Likes / dislikes: He likes all kinds of vegetables &fish.
Any change in the dietary pattern: Avoidance of irritant foods, fried, fast food and balance diet
is advice.
V. Vital Signs:
S.NO Vital Sign Normal Value Patient’s Value

1. Temperature 98.6 F 97.6 F

2. Pulse 60 – 80 Beats/M 82 Beats/M

3. Respiration 14 – 20 Breath/M 22 Breath/M

4. Blood Pressure 120/80 mmHg 135/80 mmHg

VI. Visual Analogue Scale: The pain score of my patient is (4 – 5) and the pain is radiating from left
upper limb to left lower limb.
 PHYSICAL EXAMINATION
1. GENERAL APPEARANCE
 LEVEL OF CONSCIOUSNESS : Conscious and response to all my questions
 ORIENTATION : Oriented to time and person and oriented to place
 SKIN COLOUR : Brown
 MOOD : Alert
 ACTIVITY : Active but doctor order to take bed rest
 BODY BUILD : Obese
 NOURISHMENT : Well nourished
 SPEECH : Clear
2. ANTHROPOMETRIC MEASUREMENT
 WEIGHT : 45 kg
 HEIGHT : 159 cm
 BODY MASS INDEX : 63.4kg/m2
3. HEAD TO FOOT EXAMINATION
I. HEAD
 SHAPE : Normocephalic
 SCALP : Clean
 HAIR : My patient having black hair and distributed all over the scalp.
 FACE : My patient doesn’t have any puffiness or swelling in face.
 SUBJECTIVE SYMPTOMS : No complaints
II. EYES
 EYE BROWS : Hair are equally distributed and both eyes brows are symmetric
 EYE LASHES : Eye lashes are clean and equally distributed
 EYE LIDS : Normal
 PUPILLARY REFLEX: Reacting to light
 PUPIL SIZE : Round
 SCLERA : White
 CONJUNCTIVA : Normal
 CORNEAL REFLEX : Present
 VISSION : Normal
 EYE MOVEMENT : Conjugate eye movement
 USE OF GLASSES/CONTACT LENSES : My patient is not using any type of
glasses/ contact lens.
 SUBJECTIVE SYMPTOMS : No complaints
III. EARS
 USE OF HEARING AIDS : No
 EAR CANAL : Both the canals are clean
 TYMPANIC MEMBRANE : Normal
 HEARING : Weber test is done and my patient can hear in both the ears
  SUBJECTIVE SYMPTOMS : No complaint
IV. NOSE
 EXTERNAL NOSE : Normal in shape and symmetry in size
 NASAL SEPTUM : Central
 NASAL POLYPS : Absent
 NASAL MUCOSA : There is no swelling, bleeding or any discharge
 FRONTAL & MAXILLARY SINUSES: Normal
 SMELL SENTATION : Present
 SUBJECTIVE SYMPTOMS : No complaint
V. MOUTH & THROAT
 LIPS : No redness and swelling and lip is symmetry
 TEETH : Clean
 GUMS : No bleeding is present
 TONGUE : Clean, moist all around tongue without any redness
 UVULA : No tenderness or redness
 TASTE : Normal taste present
 BAD ODOUR : Present
 TONSIL : Enlargement is not present
 VOICE : Clear
 SUBJECTIVE SYMPTOMS : No complaint
VI. NECK
 NECK : No mass is present
 RANGE OF MOTION : Possible
 THYROID GLAND : Not enlarged
 JUGULAR VEIN : Not distended
 TRACHEA : Midline
 SUBJECTIVE SYMPTOMS : No complaints
VII. THORAX AND LUNGS
 THORAX : Symmetrical
 THORAX EXPAINSION : Normal & Equal
 BREATH SOUND : 22 breath/min
 COUGH : Absent
 SPUTUM : Absent
 SUBJECTIVE SYMPTOM : No complaints
VIII. HEART
 HEART SOUND : S1 & S2 sound is present but S3 & S4 is absent
 APICAL PULSE : Absent
 PERIPHERIAL PULSE : 82 beat/min
 PACEMAKER : Absent
 OXEYGEN SUPPORT : Absent
 SUBJECTIVE SYMPTOMS : Room air
IX. GASTROINTESTINAL SYSTEM
  MOUTH : Clean
 TEETH : Clean
 TONGUE : Clean
 ORAL ULCER : Absent
 ABDOMEN : Slightly enlarge
 PERISTALSIS : Present
 NUTITIONAL ROUTE : Oral feeding
 BOWEL OPENED : Present
 APPETITE : Normal
 PERCUSSION : Presence of Air
 INGUINAL LYMPH NODE : No nodes are present
 LIVER : Normal in size
 SPLEEN : Normal in size
 KIDENY : Normal in size
 BOWEL SOUND : Present
 PERIANAL SKIN INTEGRITY : Intact
 SUBJECTIVE SYMPTOMS : No complain
X. GENITOURINARY SYSTEM
 URINATION : Self Voiding
 URINE : No sediments are present
 GENITALIA : No discharge or edema is present
 SUBJECTIVE SYMPTOMS : No complain
XI. INTEGUMENTARY SYSTEM
 SKIN : Intact
 COLOUR : Brown
 TEXTURE : Normal
 TURGOR : Normal
 HYDRATION : Good
 TEMPERATURE : 96.3F
 DISCOLOURATION : Absent
 CYANOSIS : Absent
 PERIPHERIES : Warm
 ICTERUS : Absent
 LESIONS/MASSES : No lesions/ masses are present
 SUBJECTIVE SYMPTOMS : No complaint
XII. MUSCULOSKELETAL SYSTEM
 POSTURAL CURVES : Normal
 MUSCLE TONE : Normal
 UPPER EXTRIMITIES
 SYMMETRY : Upper extremities are symmetrical
 MUSCLE STENGTH : Weakness
 RANGE OF MOTION : Possible
  BICEPS REFLEX : Normal
 TRICEPS REFLEX : Normal
 OEDEMA : Absent
 JOINTS : NO complaint
 DEFORMITY : Absent
 LOWER EXTERMITIES
 SYMMETRY : Lower extremities are symmetrical
 MUSCLE STRENGTH : Normal
 RANGE OF MOTION : Possible
 OEDEMA : Absent
 JOINTS : No Tenderness
 DEFORMITY : Absent
 GAIT : Normal
 VARICOSE VEINS : Absent
 DEPENDENCY LEVEL : Independent
 SUBJECTIVE SYMPTOMS : No complaint

CHOLELITHIASIS

INTRODUCTION
It is a common disorder of biliary system. The term “cholelithiasis” is derived from the Greek word
“chole” meaning “bile” , “lith”, meaning “stone” and “iasis” meaning “process”. Therefore , the process
of stone formation in the bile (gallbladder) is known as cholelithiasis. These stones are composed of
cholesterol, bile pigment and calcium.

DEFINITION

Cholelithiasis (calculi or gallstones) usually form in the gall bladder from the solid constituents of bile
and vary greatly in size, shape and composition.

ETIOLOGY-

L.NO ACCORDING TO BOOK ACCORDING TO PATIENT

RISK FACTORS
NON MODIFIEABLE-
Age -above 60 year
Gender – Female> male
Genetic
MODIFIEABLE Female
Obesity Eating low fiber diet
Eating high fat diet Fasting for long time
Eating high cholesterol diet
Eating a low fiber diet
Diabetes
Pregnancy
Liver cirrhosis
Fasting for long time
Biliary tract infection
Sickle cell anaemia

PATHOPHYSIOLOGY

Decreased bile acid synthesis

Increased cholesterol synthesis in the liver

 Super saturation of bile with cholesterol

Formation of precipitates

Gall stones (Cholelithiasis)

CLINICAL MANIFESTATION OF CHOLELITHIASIS

SL.NO ACCORDING TO BOOK ACCORDING TO PATIENT

1.
Pain in the middle or right upper abdomen. Spread Pain in the middle or right
below the right shoulder or to the back abdominal upper abdomen.
symptoms that occur within minutes after a meal.
Nausea
2. Abdominal swelling, distension or bloating
3. Abdominal Tenderness 2 Vomiting
4. Clay colored stools
5. Nausea Loss of appetite
6. Vomiting
7. Loss of appetite
8. Low grade fever and chills
9. Sweating

DIAGNOSTIC EVALUATION (ACCORDING TO BOOK)

 Physical examination
 History collection
 Abdominal ultrasound
 Endoscopy
  Blood test

ACCORDING TO PATIENT

 History was collected and known that my patient having the history of Gall bladder
stone(Cholelithiasis) and due to fasting for long time .
 Physical examination-on palpation abdomen is slightly enlarged and pain present.
 Endoscopy: Upper GI Endoscopy- Duodenal scar; Duodenal submucosal Lesion.
 Abdominal ultrasound-Normal in shape and size multiple calculi and echogenic sludge filling up
the entire lumen of gall bladder largest calculus measuring 11.6mm wall thickness.

SL.N INVESTIGATION PATIENT’S VALUE NORMAL INTERPRETATION

O VALUE
1. Complete blood
count
Blood studies
Haemoglobin 10.2gm/dl 13-17 Decreased.
Total Red blood 3.95ul 5.5-5.9 Decreased
cell count 33% 36- 52 Decreased
PCV 83.5fl 81-97 Normal
MCV 25.8pg 26.0-34.0 Decreased
MCH 1.5-4.5 Normal
Platelets 1.75 lakhs 4.4-11.3 Increased
Total WBC 13.26 mil/ul 40-80% Normal
different count 80% 24-40% Decreased
Neutrophil 14.7% 0-3% Normal
Lymphocytes 0.1% 4-8% Normal
Eosinophil 0.55 1-2% Decreased
Monocytes 0.3% 0-20 Increased
Basophils 60mm/1hr Increased
ESR
120-140mg/
Routine dl Normal
2. Investigation 101mg/dl <7 Fair control
RBS 6.7% 13-45mg/dl Increased
Hba1c 60mg/dl 0.5-1.5 Normal
Blood urea 1.04mg/dl 135-145 Decreased
S. creatinine 132mg/l 3.5-5 Normal
S. sodium 3.6meq/l Normal
S. potassium 95-115 Decreased
96meq/l
S. Chloride 12.4sec
PT control 1.00
INR 7.35-7.45 Normal
3. ABG 7.433 35-45mmhg Normal
PH 35.7 70-100mmhg Normal
PCO2 72.2 22-26mmol/l Low
PO2 21.9
HCO3
Urine test (on Yellow
4. 12.02.2020) Clear
Colour 2-3hpf Normal
Appearance 2-3hpf 4.8-7.5 Normal
Pus cell 5.5 1.003-1.060 Normal
PH 1.020 2-20 increased
Specific gravity Negative <10
Sugar 1+50mg/dl M-2-5,f-8-10 Increased
Protein 2-3hpf 0-2 Increased
Epith cell 4-5hpf 0.3-1.0
RBC 0.55mg/dl
5. LFT 0.1-0.4
Bilirubin(T) 0.20 5-40 Normal
BIilirubin(D) 12.40 IU/L 40-129 Increased
888.00lU/L 6.8-8.3 Normal
SGPT 6.3gm/dl Increased
Alkaline 3.3-5.2
phosphate 3.3gm/dl 2.5-3.6 Decreased
Protein 3.0gm/dl Normal
Albumin
Globulin

6 Lipid profile
Total cholesterol 190mg/dl 150-200 Normal
HDL 44mg/dl 40-60 Normal
LDL 123mg/dl 70-130 Normal
VLDL 24mg/dl 20-40 normal
Triglycerides 121mg/dl 50-150 normal

BLOOD GROUPING - A positive

Rh typing- Positive

COMPLICATION-

SL NO ACCORDING TO BOOK ACCORDING TO PATIENT

1 Gall bladder cancer
2 Blockage of the pancreatic duct
3 Blockage of the common bile duct
4 Cholecystitis
5 Obstructive cholangitis
6 Pancreatitis

MANAGEMENT
1 ACCORDING TO BOOK ACCORDING TO PATIENT
Non pharmacological measure-  Complete bed rest.
 Promote bed rest.  Eat high fiber diet
 Ensure hydration.  Ensure hydration
 Low fat diet.
 Eat high fiber foods.
 Do not skip food.

2
Pharmacological management-
 Antiemetics(To prevent or supress vomiting)
Tab. ondansetron (8mg) SOS
 Proton pump inhibitor(Supresses gastric
Tab. Pantoprazole (40mg) OD
secretion)
 Gallstone Dissolving Drugs(Dissolve in bile
with the help of bile salts)-Ursodeoxycholic
3 Acid and Chenodeoxycholic Acid
 Analgesic(To reduce pain) Tab. Tapentadol Extended
 NSAID(Relieve pain,inflammation and release (Tapal-ER) 50mg sos
fever)- Diclofenac
 Anticholinergic-Hyoscine
 Antibiotic(Cephalosporins) Tab. Taxim-o (200mg) BD
Third generation-Cefixime

Surgical management-
4. 1. Laparoscopic cholecystectomy Laparoscopic cholecystectomy
2. Open cholecystectomy

NUTRITIONAL PLAN-
Calories- 1600kcl /day
Protein- 1gm /kg/bodyweight

Fibers-30-35gms

Carbohydrate-160gm

Fluids- 1.5lit/day

PROGRESS NOTE

SL.N DATE NURSE’S NOTES

O
1. 20.12.2023 Patient was conscious and Pain. The patient had semi fowler position and
medication as ordered.
Bp- 120/80mmhg
Pulse 82/min
RR-26/min
Temp-98.4F
Spo2-100% in room air
Patient maintained urination and BP.
Advice Ultrasound and Endoscopy

2. 21.12.2023 Today patient is conscious .generalised weakness.

BP-130/80mmhg
PR-80/min
Temp-98.4F
SPO2-98%
Advice for CBC,LFT,RFT,T3,T4 and TSH
Administrate IV Fluid.

3. 22.12.2023 The patient is conscious, oriented. His vitals are stable.

Na+= 128meq/l
K+= 3.9meq/l
CL-44meq/l
HGT-134mg/dl
ABG Value
PH-7.38
PCO2-40mmhg
Po2-89mmhg
Hco3-23.01mmol/L
Na+ -142meq/L
K+ -3.4meq/L
Cl -48meq/l
HGT-124mg/dl
APPLICATON OF VERGINIA HENDERSON’S NEED THEORY IN NURSING PROCESS-

Henderson was born on 30th November, 1897 in Kansas City, Missouri and dies on 17th march 1996.

She called as “the Nightingale of modern nursing”, “Modern -day mother of nursing”

She earned her Diploma in nursing .from the army school of nursing in 1921, Bsc .in 1932, M.A in 1934.

She worked as a teaching nursing in 1923, member of faculty. And research associate.

She was honored at the annual meeting of the nursing and allied health section on the medical library
association.

She created basic nursing curriculum for nursing in 1937

She developed the theory in 1950 -1970.

She proposed 14 components of basic nursing care.

 Pain reduce
 Eat and drink adequately.
 Eliminate body waste
 Move and maintain desirable posture
 sleep and maintain desirable posture
 sleep and rest
 select suitable clothes-dress and undress
 Maintain body temperature within normal range
 Keep body clean and well groomed and protect from injury.
 Avoid dangers in the environment and avoid injuries others
 Communicating with others in expressing feeling
 worship according to one’s faith
 work in such a way that there is a sense of accomplishment
 Play and participate in various forms of recreation, learn, discover, or satisfy the curiosity that
leads to normal development.

Nursing care plan :( By q application of nursing theory)

ASSESSMENT
  patient had abdomen pain , assess the location, severity(0-10 scale) and character of pain.
 Eat inadequate diet ,she was thirsty demanded more orally fluids
 Elimination Patient was self void ,no bowel movement, since two days
 Moving: Able to move self in bed without support.
 Dressing and undressing appropriately: she was dressed independently.
 Avoiding dangers and injury to others: she was conscious and orientated and able to follow the
instruction regarding safety.
 Communication: she was able to express self clearly. Hear and saw clearly.

NURSING DIAGNOSIS:-

 Acute pain related to obstruction of gall stone in gall bladder as evidenced by patient’s
verbalization and facial expression.
 Imbalanced Nutrition less than body requirements related to Loss of appetite as evidenced by
weakness.
 Risk for deficient volume related to vomiting as evidenced by hypotension
 Anxiety related to change in health status as evidenced by insomnia and irritability.
 Deficient knowledge related to disease condition as evidenced by asking frequent question.

ASSESSMEN NURSING GOAL PLANNING IMPLEMENTATIO RATIONALE EVALUATIO

T DIAGNOSIS N N
Based on
Virginia
Henderson’s
Theory
Subjective Acute pain Patient Assess the -monitored To identify Patient pain
data: related to will be cause ,locati location, duration, type and was
Patient says obstruction relief on and intensity of pain, severity of relieved .
that feel pain of gall abdomina severity of by using 0 to 10 pain. She feel
in abdomen, stones in l pain and pain scale in pain scale. comfort.
indigestion, gall bladder decreased
aggravated as in pain -Monitored blood
pain after a evidenced scale . pressure, pulse
heavy meal by patient Monitor vital and respiration. -To obtain
from 6-7 days verbalizatio signs baseline
n and facial -Provide data.
expression. comfortable
Objective data: Provide position by lying - To feel
Tenderness and comfortable on left lateral comfort.
rigid abdomen position position.
right upper
quadrant and
-Administered
facial
expression
Analgesic as per
VAS-4-5 doctor’s advice- -To relieve
Administere Diclofenac. pain
d Analgesic

Imbalanced Patient Assess the Checked To collect Patient’s

Subjective nutrition nutritional nutritional nutritional status the baseline nutritional
data: less than status will status and data status was
Patient says body be needs of the improved as
that feel requirement improved patient evidenced by
weakness, related to increase
indigestion loss of Assess the Checked weight- To identify weight
and nausea appetite as weight and 45 KG BMI
Objective evidenced BMI BMI-63.4kg/m2
data: by Advice for To prevent
Abdominal weakness healthy diet Advice for healthy indigestion
pain score diet like high-fiber
increased, food and avoid fat
Weight diet
decreased
BMI-
underweight Encourage Rest for 6-7 hours
patient for To easily
bed rest Administered IV digestion
fluid like NS,
DNS and RL as
Administere per doctor’s order
d IV fluid To improve
As per hydration
 doctor’s
order

Subjective Risk for Patient Assess Assessed the To know the Patient was
data: deficient will be source of vomiting- fluid and improved
Patient says fluid improved fluid and Episode, colour electrolyte fluid and
that she is volume in fluid electrolyte status electrolyte
having related to and loss BP-
nausea and vomiting as electrolyt 120/76mmH
vomiting evidenced e status Monitor vital Monitor vital To collect g
by sign sign-BP, pulse the baseline
Objective hypotension and respiration data
data ; . Monitor
BP- input and Maintain input To know
100/65mmHg output and output chart volume
Dull face hourly status
Fatigue Administer
IV Fluid as Administered IV To maintain
per doctor’s Fluid like electrolyte
advice NS,DNS and RL balance
as per doctor
advice

Subjective Anxiety Patient Asses the Assessed To know the Patient

data: related to anxiety patient behavioural baseline data anxiety was
Patient having change in will be anxiety level response. reduced
stress and health status reduced some extent.
worried about as Encourage to
disease evidenced take rest Encouraged to To reduce
by insomnia take 6-7 hours stress
Objective and Provide
data: irritability diversional Provided
Anxiety and therapy diversional To feel relax
insomnia therapy like
listening music,
Provide reading book etc
psychologica
l support Provided To maintain
psychological good
support Interpersonal
relationship

Subjective Deficient Patient Assess the Assess the patient To educate Patient was
data: knowledge will be patient know odia the patient in gain
Patient says related to gain language and language their own knowledge
that lack of disease knowledg include language and on disease
knowledge condition as e family at their own condition
regarding evidenced regarding members or level of and home
disease by asking the significant understandin care
frequent disease others in g management
Objective question condition teaching.
data:
Asking Advice Advice to eat high To know the
frequent regarding fiber food and good
question food avoid fat food nutrition

Educate the Educate the

disease disease condition
condition its causes, sign To gain
and symptoms, knowledge
complication and regarding the
treatment disease
condition

HEALTH EDUCATION-

DIET-

- Advice do not skip meals.

- Advice to intake sufficient water.
- Advice to eat high- fibre diet.
- Avoid high spicy and fatty food.
- vital signs and weight regularly.

Management of disease condition

- Teach the patient and family members about cause , effects, treatment, prognosis and
complication of cholelithiasis.
- Teach the patient to recognize and report complication like pain , weakness, nausea and vomiting,
- Advice to avoid stress and strain.
- Advice the family members for provide home care to the patient.
- Teach relaxation techniques i.e like watching TV ,reading newspaper, 562-meditation.
- Do regular exercise to maintain healthy weight.
- Teach the family members about support the patient psychologically and physically
- Teach them about sign and symptoms of disease and complication ,if any occur then
immediately consult with physician.

Medication

- Teach the patient and family member about time and frequency of taking medication.
- Teach the family members for skip of drug may induce serious complication.
 - Teach about side effects of medication.
- Advice to complete the course of medication.

Follow up-

- Instruct the patient to review for re-checkup as a prescribed.

- Advise that if any side effects occur then report to the physician.
- Advice for regular CBC, TSH, T3 and T4.

CONCLUSION

Cholelithiasis is the medical name of hard deposits(gallstone) that may form in the gall bladder. Gall
stone usually form from the solid constituents of bile and may be as a grain of sand or as large as a golf
ball. Cholelithiasis is the presence of gall stones, which are solidification that form in the biliary tract,
usually in the gallbladder. Predisposing factor of cholelithiasis 4F’S Fat, Forty, Female and Fertile.

Early detection of symptoms and prompt management is necessary to prevent the further complications
and prevent the patient from life threatening condition.

BIBLIOGRAPHY

 BRUNNER & SIDDHARTH’S. TEXTBOOK OF MEDICAL SURGICAL NURSING;

11TH EDI; NEW DELHI: REED ELSEVIER. - (P) LTD PAGE NO-562-568
 TRIPATHY KD.ESSENTIAL OF MEDICAL PHARMACOLOGY; SEVENTH
EDITION; JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD. PAGE NO-661-
671
 LEWIS TEXTBOOK OF MEDICAL SURGICAL NURSING ;NINTH EDITION ;NEW
DELHI; ELSEVIER P- 1106-1120