2. GENERAL OBJECTIVE
• At the end of the case study we will able to
provide holistic nursing care to the patient by
applying nursing process with the
comprehensive knowledge of the client’s
physical, mental, social and spiritual status
within the hospital stay.
3. SPECIFIC OBJECTIVES
• To provide the holistic nursing care to the client using
nursing process.
• To gain knowledge about one specific disease and its
nursing management.
• To identify the causes of specific disease and its clinical
feature in the patient.
• To take detail health history of the patient related disease.
• To collaborate with patient, family and health staffs for
proper management of the patient from admission to
discharge.
• To perform general and systematic physical examination in
logical sequence.
4. • To analyze the finding of patient’s general health and
physical examination.
• To formulate appropriate nursing diagnosis and care
plans on the basis of priority of patients’ need.
• To explain the pathophysiology of patient’s disease
condition and application of this knowledge in planning
nursing care.
• To explain and demonstrate sensitivity to the need of
patient and assist them toward own care as they
improve.
• To alleviate pain, discomfort and stress, of patient by
using nursing measures.
6. BIO-DEMOGRAPHIC DATA OF PATIENT
• Name of patient : Mrs. Bhana devi saud
• Age : 59 yrs
• Sex : Female
• IP no : 1215
• Bed : 8
• Ward : Intensive Care Unit
• Provisional diagnosis : Acute severe bronchial Asthma
• Final diagnosis : Acute severe bronchial Asthma
• Date of admission : 2074/11/10
7. • Religion : Hindu
• Occupation : Farmer
• Education : Literate
• Address : Tikapur-3, Kailali
• Age group : Middle Adulthood
• Attending doctor : Dr. Sanket Risal
• Date of interview : 2074/11/ 11
• Date of discharge : 2074/11/16
• Informants : Visitors, patient and
patient’s documents, doctor and ward staffs.
8. Chief complain:
• Patient said that, “I have shortness of breathe, Loss of
appetite since 3 days.”
HEALTH HISTORY
Present health problems:
• According to my patient she had difficulty in breathing,
shortness of breathe, loss of appetite, cough, since 2-3
days Onset was acute, so she came to Emergency
department of Bheri Zonal Hospital and shifted her to
intensive care unit for observation.
• Alleviating factors: While taking rest.
• Aggravating factors: dust, exhaustion and allergens
9. Past medical history
• Immunization : Not significant
• Any drug allergy : Not significant
• Previous hospitalization: yes, due to same
cause .
• Any medication: Not any
• Any chronic disease: Not any
• No any history of injury and accident.
• Surgical history: Not any
10. PERSONAL HISTORY/HABITS
Dietary habits
• Meal timing : 8 am, 12 pm, 7pm
• No of meals : 3 meals per day
• Food dislikes : Not significant
• Food allergy : Not significant
• Recreational habit: Watching T.V. and Listening music (especially in
radio)
• Rest and sleep : 8 hours at night and also day napping
• Personal care habit: Adequate
• Elimination habit: Regular bowel and bladder habit
• Smoking and drinking habit: Not any drinking and smoking habit.
11. FAMILY HISTORY
• She lives in a nuclear family of 5 members
including her husband ,her 1 sons and 1
daughter.
• She has 2 sons and 1 daughters; one of the
son is married.
• She is unknown about cause of the death of
her father and grandparents and also about
their diseases condition.
• Not any history of chronic illness in her family.
12. HOME ENVIRONMENT
• House structure : Cemented
• No. of rooms :6
• Kitchen : separate
• Kitchen garden : yes
• Fuel used : LPG gas and firewood
• Sources of drinking water :Hand pump
• Type of toilet :water-sealed toilet
• Refuse disposal :composting and burning
13. SOCIO-ECONOMIC HISTORY
• They belong to middle-class economic group. The source
of income is agriculture and her son is also engaged in
business.
• Has good relationship with family and neighbors.
OCCUPATIONAL HISTORY
• She is a housewife but due to illness her activity altered.
PSYCHOLOGICAL HISTORY
• She has no any psychological problems yet.
HEALTH BELIEFS AND PRACTICES
• She has faith on both medical treatment and traditional
healers.
• She has faith on god and celebrates all festivals and
cultures of Hindu religion.
14. Family tree
Paternal side Maternal side
(Unknown cause)
INDEX:
=Dead male
=Dead female
=Male
=Female
=Patient
15. Physical Examination
Anthropometric Measurement:
• Height - 160 cm
• Weight- 58kg
• BMI- 23
Vital Signs:
• Temperature- 98 ͦ F
• Pulse-90b/min
• Respiration -28/m
• Blood pressure -140/90 mm of Hg
• Spo2 - 86% without oxygen
16. Findings of physical examination
Hot and flushed skin
Forceful breathing
Shortness of breath
Wheezing sound present on auscultation
Hyper-resonance sound present on percussion
Mild dehydration
18. Book picture
• Express love through more
than sexual contacts.
• Maintain healthy life patterns.
• Develop a sense of unity with
mate.
• Help growing and grown
children to be responsible
adults.
Patient picture
• Achieved
• Achieved
• Achieved
• Achieved
19. • Relinquish entral role in
lives of grown children.
• Accept children's mates and
friends.
• Create a comfortable home.
• Be proud of
accomplishments of self
and mate/spouse.
• Achieved
• Achieved
• Achieved
• Achieved
20. • Reverse roles with aging
parents.
• Achieve mature, civic and
social responsibility.
• Adjust to physical changes
of middle age.
• Use leisure time
creatively.
• Achieved
• Achieved
• Achieved
• Achieved
21.
22. The organs of the respiratory system are:
• nose
• pharynx
• larynx
• trachea
• two bronchi (one bronchus to each lung)
• bronchioles and smaller air passages
• two lungs and their coverings, the pleura
Muscles of Respiration
Diaphragm & intercostals muscles
23. LUNGS
Lungs are pair of respiratory organ situated in the
thoracic cavity .The right and left lung are separated
by mediasternum. There are two lungs in human being
and they are:
1. Right lung
2.Left lung
1. Right lung ; it has 2 fissure and 3 lobes.it is larger and
heavier than left lung it’s weight is 700gram.it is shorter
and broader.
2.Left lung ; it has only 1fissure and 2 lobes.it is smaller
and lighter than right lung it’s weight is 600gram.it is
longer and narrower.
24.
25. STRUCTURE OF LUNGS
• Each lungs is divided and described into five
parts:
1. Apex :The apex is rounded and rises into the root
of the neck.
2. Base : The base is concave and semi lunar in
shape and closely associated with thoracic
surface of the diaphragm.
3. Costal surface : the costal surface is convex and
is closely associated with the costal cartilage,
ribs and the intercostals muscles.
26. • Medial surface ; the medial surface is concave
and roughly tringular shaped area.
• Hilus ; it is situated on the medial surface ,it
lies at the level of 5th,6th,and 7th thoracic
vertebrae
27. BRONCHI AND BRONCHIEOLES
• The trachea divides into a right primary
bronchus and left primary bronchus which go
to the right and left lungs respectively.
• Like the trachea, the primary bronchi contain
incomplete rings of cartilage and are lined by a
pseudo stratified ciliated epithelium.
28. • The primary bronchi divide to form smaller bronchi
called the secondary (lobar) bronchi.
• The secondary bronchi continue to branch, forming still
smaller tubes called tertiary (segmental) bronchi that
divide into bronchioles.
• Bronchioles, in turn, branch into even smaller tubes
called terminal bronchioles.
• Terminal bronchioles subdivide into microscopic
branches called respiratory bronchioles. As the
respiratory bronchioles penetrate more deeply into the
lungs, the epithelial lining changes from cuboidal to
squamous.
• Respiratory bronchioles, in turn, subdivide into several
alveolar ducts. This continuous branching from the
trachea resembles a tree trunk with its branches and is
commonly referred to as the bronchial tree.
29. Functions of respiratory system
1. supplies the body with oxygen and disposes of
carbon dioxide
2. filters inspired air
3. produces sound
4. contains receptors for smell
5. rids the body of some excess water and heat
6. It regulates acid base balance by excreting co2
from the body
7. Mechanism of respiration : inspiration ,
expiration , pause .
30. Mechanism of respiration
Inspiration
Expansion of chest so thoracic cavity Allow increase.
Diaphragm and intercostal muscles contract.
Same time external intercostal muscles pull the ribs
upward and outward increase the volume of thoracic
cavity.
Volume of thoracic cavity increases, intra thoracic
pressure decrease.
Inspiration occur :High pressure(atmosphere) to lower
pressure (lung)
31. Expiration
• Diaphragm and intercostal muscles relax.
• Volume of thorax decrease
• Stretched alveoli now recoil reducing intra
pulmonary volume.
• Pressure decrease due to thoracic volume
decrease
• Constriction of the lung increase pressure
inside thoracic cavity
• Cause air move out so expiration occur
32. Pause
After each inspiration and expiration there is a
small rest called respiratory pause. Then
continue inspiration and expiration
33. Disease Profile
Definition
Asthma is a chronic inflammatory disorder of
the lower airway due to temporary narrowing of
the bronchi by bronchospasm manifested as
dyspnea (usually expiratory), wheezing and
excessive cough.
34. Incidence
• Asthma is a reversible lung disease that may resolve
spontaneously or with treatment.
• According to the CDC, more than 25 millon Americans,
including 6.8 million children under age 18, suffer with
asthma.
• It is a global problem affecting around 300million
individuals of all ages, ethnic group and countries.
In Bheri Zonal Hospital
Paying and General ward
4 cases of Asthma out of patient 1Male and 3 Female
from (Shrawan 2074 to Falgun 2074).
35. Types of Bronchial Asthma
Two type :
• Allergic or extrinsic asthma
• Non- allergic or intrinsic asthma
In most cases, it is mixed type.
36. Allergic or extrinsic asthma
• It is produced by a hyperimmune (IgE) response to the inhalation of
specific antigen (pollen, dust, feather etc.)
• Antigen and antibody reaction is stimulated by extrinsic triggers.
• Antigen combines with IgE causing the mast cell to degranulate and
release chemical mediators (histamine, leuckotrienes,
prostaglandin).
• Chemical mediators act on bronchial smooth muscle to cause
bronchoconstriction, increase mucus secretion and cause cellular
infiltration and inflammation.
37. Non- allergic or intrinsic asthma
• Also called as non - IgE mediated
• Unidentified or non-specific factors of the
environment like cigarette smoke, perfumes,
drugs, change in temperature, viral respiratory
infections, emotional stress, excitement etc.
38. Causes of Asthma
Book picture
Family history of asthma
Allergens or Irritants
Weather changes
Exercise, cold air
Emotional factors
Genetic factors
Passive smoking
Patient picture
Present
Cold weather
Present
39. Pathophysiology of Asthma
Expose to Allergen/contributing factor/irritants
(Stress, cold air)
Inflammation
IgE stimulation (IgE always responds to allergens)
Mast cell activated
Mast cells secret histamine, prostaglandin, bradykinin and
leukotrein
41. Clinical Manifestation
Book Picture Patient Picture
Chronic cough, dyspnea, shortness
of breathe
present
Sputum production absent
Headache, chest tightness,
tiredness, weakness
On percussion Hyper-resonance
sound present
present
Pallor or cyanosis, chest tightness,
fatigue, diaphoresis
Diaphoresis present
On auscultation wheezing sound
present
present
42. Diagnosis
Book picture Patient picture
History taking Done
Physical examination Done
Pulse oxymetry
examination
Done (SPO2 86% without
oxygen on admission)
Chest x-ray Done(bilateral trapping of
air seen)
47. Book picture Patient Picture
Smoking and drinking
cessation
Avoidance of allergens and
pollens
Done
Chest physiotherapy Done
Oxygen therapy at 2-3l/m Done
Medications :
•Steroids Inj. Hydrocortisone 200mg I/V
TDS
•Bronchodilators Asthalin and Ipravent
nebulization 6 hourly and SOS
48. Antibiotics and other medications Inj. Clavum 1.2 gm I/V TDS
Inj. Levoflox 750 mg I/V OD
Tab Azilide 500 mg PO OD
Inj . Omez 40 mg I/V OD
50. INJ CLAVUM
MOA:
• It works by preventing the formation of the bacterial
protective covering which is essential for the survival of
bacteria in the human body.
Adverse effects:
• Diarrhea, Nausea, Vomiting, Diarrhea, Cholestatic
jaundice, Anemia, Agitation, Anxiety, Insomnia,
Confusion
Nursing consideration:
• Do not mix this drug with other antibiotic.
• For IV injection, the medicine should be mix with
minimum of 6-10 of distilled water.
51. INJ LEVOFLOX
MOA
Levofloxacillin belongs to a class of drugs known as
quinolone antibiotics. It works by stopping the growth of
bacteria.
Side effects:
redness/swelling at the injection site, nausea, diarrhea, headache
,dizziness, Lightheadedness, severe/persistent headache ,vision
changes
Nursing consideration
• Assess hypersensitivity; report neurologic effects.
• Maintain intake and output chart.
• Donot take with vitamins/mineral supplements (or wait 2 hrs
before and after)
52. INJ HYDROCORTISONE
• Mechanism of action:
binds to intracellular glucocorticoid receptors and
suppresses inflammatory and immune response.
• Side effects:
hyperglycemia, osteoporosis, psychological
disturbances, delayed wound healing, rapid wt gain etc.
• Nursing consideration:
Steroid should be use in lowest dose if possible.
Never change or stop the dosage except as directed.
Monitor side effects.
Always give H2 blocker with cortisone.
Never stop the drug suddenly, it should be stop after
tapering the dose.
53. INJ AZITHROMYCIN
• Mechanism of action:
It inhibit protein synthesis at the level of
bacterial ribosome. it attains high concentration in
tissue and macrophages and polymorph.
• Side effects:
Nausea, vomiting, diarrhea, headache,
urticaria, dizziness, vertigo etc
• Nursing consideration:
Observe the sign and symptoms of anaphylaxis.
Administer 1hr before or 2hr after meal for best
absorption.
54. INJ ASTHALIN
• Mechanism of action
it accumulates of cAMP at B-adrenergic
receptor so its effect is bronchodilator.
• Side effects
tremor, headache, tachycardia, nausea,
anorexia palpitation etc..
• Nursing consideration
• watch the sign and symptoms of allergic reaction.
55. INJ IPRAVENT
• Mechanism of action
it block acetylcholine effect effects in bronchi and
bronchioles and relaxes smooth muscles causes
bronchodilation.
• Adverse effect
tachycardia, weakness, convulsions, tremor
• Nursing consideration
• Watch for signs of CNS stimulation in children symptoms such
as insomnia, excitement, nervousness etc.
• Watch for hypersensitivity reaction
• Watch for signs of tremor
57. Prognosis
• The prognosis for asthma is generally good.
• Asthma diagnosed during childhood, half of cases
will no longer carry the diagnosis after decade.
• Early treatment with corticosteroid seems to prevent
decline in lung function.
• Mortality has decreased over the last few decades due
to better recognition and improvement in care
58. Prevention
Patient with recurrent asthma should undergo
testes to identify substances that precipitate
symptoms.
Reducing or eliminating compounds known to
sensitive people from the work place may be
effective.
Patients are instructed to avoid causative agents
whenever possible.
Smoking bans are effective in decreasing
exacerbations of asthma.
59. Progress of my patient
Admissio
n day
2074/11/
10
1st day
2074/11/11
2nd day
2074/11/1
2
3rd day
2074/11/13
4th day
2074/11/14
Vital sign
• Blood
pressure
• Pulse
• Temperature
• Respiration
Diet
• 140/100
mm/hg
• 64b/m
• 100⁰F
• 28/m
• Liquid
diet
• 140/90mm
/hg
• 72b/m
• 99.4⁰F
• 28/m
• Liquid diet
• 130/80m
m/hg
• 86b/m
• 98.6⁰F
• 28/m
• soft
• 130/80mm
/hg
• 82b/m
• 98.6⁰F
• 24/m
• Normal
diet
• 120/80mm
/hg
• 78b/m
• 98.2⁰F
• 22/m
• Normal
diet
Investigation
advised
CBC, • ECG , chest
x-ray
_ Echo
screening
_
Round
instructions
• Collect
investig
ation
report
• Continu
oxygen,
chest
physiotherapy
• CST • CST and
plan for
ward shift,
O2
intermitte
nt
• CST
60. 5th day
2074/11/15
6th day
2074/11/16
Vital sign
• Blood pressure
• Pulse
• Temperature
• Respiration
Diet
• 120/80mm/hg
• 78b/m
• 98.2⁰F
• 22/m
• Normal diet
• 120/80mm/hg
• 78b/m
• 98.2⁰F
• 22/m
• Normal diet
Investigation advised _ _
Round instructions • CST and plan
for discharge
tomorrow.
• Discharged and
follow up after 2
weeks.
61.
62. 14 . Basic component of Nursing
1 to 9
Psychological aspect of
communicating &
learning
10 to 14
Spiritual and
moral
Sociologically oriented
occupation and
recreation
12 & 13
11
63. Demographic Data
• Name of patient : Bhana devi saud
• Age : 59 yrs
• Sex : Female
• IP no : 1215
• Bed : 8
• Ward : Intensive care unit
• Provisional diagnosis : Bronchial asthma
• Final diagnosis : Bronchial asthma
• Date of admission : 2074/11/10
• Religion : Hindu
• Occupation : Housewife
• Education : Literate
• Address : Tikapur -1 Kailali
• Age group : Middle Adulthood .
64. Nursing assessment of Mrs. Bhana
devi saud
S.N Henderson’s 14 component Assessment(Findings)
1. Breath normally She was experiencing difficulty in breathing; She had
persistent cough and also shortness of breathe.
2. Eat and drinks adequately She had loss of appetite.
3. Eliminate waste products Bowel and bladder habit were normal.
4. Move and maintain desirable
position
She was able to move and maintain desirable position.
5. Sleep and rest She was not able to sleep because of unfamiliar environment.
6. Select suitable cloths She was wearing loose fitting clothes.
7. Maintain body temperature She had fever, temperature is 101.4⁰F.
65. 8. Keep the body clean and groomed She was not well groomed.
9. Avoid dangerous environment She reports weakness.
10
.
Communicate with others in expressing
emotions, needs, fears or opinions
Communicates normally.
11
.
Worship according to one’s faith She is hindu and has total faith in god and her
cultural values.
12
.
Work in such a way that there is a sense of
accomplishment
She was a Housewife but routine is altered due her
condition.
13
.
Work in such a way that there is a sense of
accomplishment
She enjoys watching T.V. and listening music.
14
.
Learn, discover or satisfy the curiosity that leads
to normal development and health and use the
available health facilities.
She is curious about her disease condition and the
prognosis.
66. Nursing Diagnosis
Breath normally Impairment in normal breathing pattern
related to persistent cough as evidenced by
respiratory rate: 30b/min.
Maintain body temperature Alteration in body temperature related to
inflammatory process as evidenced by hot and
flushed skin and temperature 101.4⁰F.
Eat and drinks adequately Imbalanced nutritional status related to loss of
appetite as manifested by lack of interest in
food.
.
67. Sleep and rest Alteration in sleeping pattern related to
unfamiliar and noisy environment as
manifested by restlessness, irritability and
blank facial expression.
Learn discover and satisfy the
curiosity
Deficient knowledge related to disease
process and treatment regimen
68. 1. Impairement in normal breathing pattern related to
persistent cough and heaviness in chest as
evidenced by respiratory rate: 30 b/min.
Goal : Short term goal
After 1-2 hours of nursing Intervention he will re-
establish regular breathing pattern.
Planning/Implementation:
1. Kept the patient in comfortable position.
2. Assessed respiratory rate, pattern and depth position
for breathing.
3. Administered humidified oxygen.
4. Elevated head of the bed.
5. Provided chest physiotherapy.
69. Evaluation:
After 2 hour of nursing intervention patient was
able to breath in regular pattern and breathing
rate was 26 b/min.
70. 2. Alteration in body temperature related to
inflammatory process as evidenced by hot and
flushed skin and temperature 101.4f
Goal : short term goal
Body temperature will be reduce to normal(98 ° F )within
2 to 3 hours.
Planning/Implementation
Assessed the general condition of the patient and his
body temperature by palpating the skin and the skin
appears flushed and warm and sweating present
Monitored the vital signs , particularly temperature and
the temperature was 103 °F
Removed warm clothes and blankets from the body.
71. • Maintained cross ventilation by opening
windows and doors.
Applied tepid sponge for 20 minutes.
Encouraged to drink oral fluid.
Gave antipyretic medicine according to doctor’s
order.
Took the temperature by thermometer after half
an hour.
Evaluation
After 2 to 3 hour of nursing intervention patient’s
body temperature was reduced up to 98°F.
72. 3.Imbalance nutritional status related to loss of interest
in food as manifested by lack of interest in food.
Goal : long term goal
Improvement of appetite within hospitalization.
Planning/ Implementation:
1. Assessed nutritional status.
2. Took history of nutritional status.
3. Maintained oral hygiene.
4. Provided patient’s food preference within dietary
restriction.
5. Explained rational for dietary restrictions.
6. Offered small frequent meal in pleasant environment.
73. Evaluation :
• Patient finally verbalized to have juice and also
understands dietary importance before my
shift was over and improvement in dietary
pattern was seen during hospitalization.
74. 4.Alteration in sleeping pattern related to unfamiliar and noisy
environment as manifested by restlessness, irritability and
blank facial expression.
Goal: long term goal
Patient will achieve optimum amount of sleep during
hospitalization
Planning/Implementation:
1. Assessed past pattern of sleep.
2. Documented sleeping & wakeful behaviors.
3. Advised patient to increased day activities & discourage day
naps.
4. Suggested use of soporifics such as milk before going to bed.
5. Recommended environment conductive sleep ( quite
environment, ventilation, darkness).
76. 5.Knowledge Deficit about the disease process and
treatment regimen related to a lack of information,
evidenced by questions & request for information,
verbalization of concern.
GOAL
• Anxiety of the patient will be reduced with in 2 hours.
• Patient will be verbalized understanding of the desire content and
perform desired skill.
PLANNING / IMPLEMENTATION:
• Assess any doubt , question , pre –existing level of knowledge ,
understanding level.
• Encourage to verbalize feeling , concern , question, and nay kind of
fear about the problem.
• Make patient comfort and allow ask all the doubt and question with
out any fear regarding the disease condition and the treatment
regimen.
• Use different learning format like programmed books, audio video
tapes ,leaflet, pamphlet , question answer session.
77. Evaluation :
• Reduce anxiety and stress about the
condition and feel ease and comfort.
• Verbalize understanding of condition ,
potential , individual risk factors ,possible
effects of the disease.
• Correctly perform necessary healthy habits.
78. Stress Management
Following measures were taken for stress management
in my patient:-
• Build a good rapport with the patient and family
members.
• Gave complete orientation about ward, routine of
wards, rules and regulations.
• Thoroughly explained about disease condition, its
management and modification therapies etc.
78
79. Following measures were taken for stress
management in my patient:-
• Build a good rapport with the patient and family
members.
79
80. • Gave complete orientation about ward, routine of
wards, rules and regulations.
80
83. • Encouraged patient in self-care and also
motivated family members to assist her in daily
living activities and other works.
83
84. • Advised to make coping strategies:-positive
thinking, set priorities and limits and develops
sense of humor.
84
Set
priorities
and
limits
Devel
op
sense
of
humo
r
104. Things I have learned from this case study
• Gained detailed knowledge about patient and family.
• Gained detailed knowledge about disease condition, and
its management.
• Learned to apply Nursing Theory
• Got chance to apply theoretical knowledge into
practical.
• Increase self confidence for further case study.
105. SUMMARY
As partial requirement of my case study, I was posted on medical surgical ward
(adult) of Bheri Zonal Hospital for 2 weeks. I chosen the case of ASTHMA
for detail study. My patient Mrs. Bhana devi saud 59yrs/Female came to
hospital on 2074/11/10 with the chief complain of cough, dyspnea, loss of
appetite. She belongs to middle socio- economic group.
During hospitalization, I provided her care regarding her need by
applying nursing process. Medicines used in my patients are antibiotics,
antipyretics and oxygen therapy.
During hospitalization I gave informal health teaching on various
topic like nutrition, personal hygiene, medication and its side effects, avoiding
dusty and dirty environment to patient and visitors. Different type of stress
management techniques were taught and he was discharged on 2074/11/16 .
She was provided discharge teaching on proper rest and sleep, avoidance of oily
and fried foods, use of diversional therapy, e.t.c.
106. REFERENCES
• Brunner and shuddarth(2012), Text book of medical and surgical
nursing, 12th edition, walters kluwer(India) pvt. Ltd, New Delhi.
• Rai L. (2011), Nursing concept theory and principle,2nd edition ,
Nabin k. Rai, Kathmandu. Smeltzer, c and et.al (2010).
• Ross and Wilson(1988), Anatomy and Physiology, 6th edition,
longman group FE Ltd.
• Tripathi K.D.(2008),essential of medical pharmacology,6th edition,
jayapee brothers medical publisher private LTD New Delhi
• Tuitui R. (2005), pocket book of drugs,2nd edition, Makalu books
and stationers, Putalisadak
• Mandal GN 2012,Text book of adult health, 1st edition, Makalu
publication, dillibazar, Kathmandu
• www.wikipedia.com/prognosis/complications/anatomy and
physiology
