This document discusses quality assurance in nursing. It defines quality assurance as monitoring nursing activities to determine the level of excellence in patient care. The document outlines the components of a quality improvement program, including establishing accountability, defining key aspects of service, developing quality indicators, and communicating results. It also discusses different approaches to quality assurance programs, such as general and specific approaches, as well as nursing audits as a method of evaluating nursing documentation and care.

1. GOVERNMENT COLLEGE OF
NURSING RAJNANDGOAN (C.G.)
Guided By
Mrs. Shraddha P.Kumar
Demonstrator
Medical Surgical Nursing
G.C.O.N.
Rajnandgoan
Presented By
Tulsi Dhidhi
M.Sc. Nursing 1st Year
SUBJECT -ADVANCED NURSING PRACTICE
SEMINAR ON QUALITY ASSURANCE IN NURSING

2. INTRODUCTION
•The field of quality assurance is as old as modern nursing
florence Nightingale introduced the concept of quality in
nursing care in 1855 while attending the soldiers in the nospital
during the crimean war.

3. DEFINITOIN
•1. Quality assurance in a judgment concerning the process of cure based on
the extent to which that cares contributes to valued outcomes.
•(Donabedium 1982)
•2. Quality assurance is the monitoring of the activities of client care to
determine the degree of excellence attained to the implementation of the
activites.
•(Bull,1985)
•3. Quality assurance in the defining of nursing pructice through well writen
nursing standards and the use of those standards as a basis for evaluation on
improvement of client care.
• (Maker 1998)

4. CONCEPT OF QUALITY IN HEALTH CARE:
Defining quality is difficult. The expense of quality is an
interactive process between customer and provider. The
customer does not receive anything tangible, mostly only a
piece of paper with a promise for a better future e.g.. Doctors
write prescriptions.
Principles:
1. Customer focus
2. Leadership
3. Involvement of people
4. Process approach
5. Factual approach to decision making

5. PRINCIPLE
Leadership

8. Component of quality improvement programs
1. Establish responsibility and accountability for a Q.I program.
2. Define the scope of service for a clinical area
3. Define the key aspects of service for the clinical area.
4. Develop quality indicators to monitor the outcomes and
appropriateness of care delivered.
5. Establish thresholds for evaluation of indicators.
6. Collect and analyze data from monitoring activities.
7. Evaluate results of monitoring activities to determine the need for
change in practice.
8. Resolve problems through development of action plans.
9. Reevaluate to determine if the plan was successful
10. Communicate Q.I results to the organization

9. APPROACHES FOR A QUALITY ASSURANCE PROGRAM:
Two major categories of approaches exist in quality assurance they are
1. General.
2. Specific.

13. NURSING AUDIT
•Introduction :
•Nursing audit is a review of the patient record designed to identify
examine or verify the performance of certain specified aspects of
nursing care by using established criteria.
•A concurrent nursing audit ; is performed during ongoing nursing
care.
•A retrospective nursing audit : is performed after discharge from
the care facility using the patient’s record.
•Definition :
•According to Elison “Nursing audit refers to assessment of the
quality of clinical nursing. “
•

14. HISTORY OF NURSING AUDIT
Nursing audit is an evaluation of nursing service. Before
1955 very little was known about the concept. It was
introduced by the industrial concern and the year 1918 was
the beginning of medical audit.
George groword pronounced the term physician for the first
medical audit. Ten years later Thomas R Pondon MD
established a method of medical audit based on procedure’s
used by financial account. He evaluated the medical care by
reviewing. The medical records.
First report of nursing audit of the hospital published in 1955
for the next 15 year nursing audit in reported from study or
record on the last decade. The program is reviewed from
nursing plan, nurses notes patient condition nursing care.

15. Purposes of Nursing Audit:
1. Necessitating adequate documentation of nursing care provided
to the client through the entire nursing process.
2. Directing attention to the design and utility of the charting record.
3. Encouraging the use of the problem oriented nursing system.
4. Supporting and becoming an integral part of nursing by objective
program
5. Facilitating the co-operative planning and delivery of client care
by physicians and nursing employees.
6. Increasing the priority for results oriented performance
evaluation program for nursing service employees.
7. Enriching and providing direction to in service education effects.
8. Providing a specific management technique in carrying out
evaluation and control function.
9. Identifying ways to improve patient care.
10. Providing a meaningful ways for nursing staff members to
participate and achieve career growth.

16. Concept Of Nursing Audit: Nursing Audit mainly
comprises of
1) Debit
2) Credit
I. Debit: Debit is all negative activities in nature e.g.
Hospital infection.
II. Credit: Credit mainly involves all positive activities in
nature
E.g. Satisfactions of care.
Debit Items of Nursing Audit:
1. Death of the client not justifiable as otherwise could
have been prevented.
2. Complications due to the neglect of nursing care.
3. Complications of diseases leading to morbidity. 4.
Hospital infection.
5. Errors in treatment.
6. Clients discharged against medical advice.
7. Absence of total client care.
8. Lack of application of nursing process.

17. CREDIT ITEMS IN NURSING AUDIT:
i) No. of recovered patients.
ii) Shortens stay in the hospital.
iii) Expansion of health knowledge in client
population.
iv) Research as need for problem oriented care
approach.
v) Regular follow up in the community.
vi) Measures to improve the public image. 132
vii) Well maintained nursing audit

18. AUDIT CYCLE

19. 2. Measurement of Actual Practice against Criteria This
means to secure the charts from medical records (possibly
by random selection, collect the necessary data, measure
the result against set standards.
3. Evaluation of the results
4. Action taken to correct deficiencies
5. Follow up and reassessment
6. Report to nursing service administration and needed
staff
Types Of Nursing Audit:
(i) Structure audit: The inspection of the management process
as carried out and documented by the nurse manager.
(ii) Process audit: In this type of audit inspection of the nursing
process, as carried out and documented by staff nurses to
evaluate competence with established standards of nursing care.
(iii) Outcome audit: It mainly identifies client outcomes
(satisfactory and unsatisfactory and the patterns of nursing care
that appears to be responsible.

20. Methods of Nursing audit
A) Retrospective view; This refers to an in depth assessment
of the quality after the patient has been discharged have
the patients charts to the source of data.
B) The concurrent review : This refers to the evaluation
conducted on behalf of patients who are still undergoing
care. It includes assessing the patient at the bedside in
relation to predetermined criteria interviewing the
responsible for this care and reviewing the patients
record and care plan.

21. Advantages Of Nursing Audit: - Method of measurement.
- Functions are easily understood. - Scoring system is
fairly simple. - Results are easily understood. - Assess
the work of all those involved in recording case. - May be
useful tool as part of a quality assurance program in
area where accurate records of case are kept.
Disadvandages Of Nursing Audit: - It is not so useful in
areas where the nursing process has not been
implemented. - Many components overlap making
analysis difficult. - It is time consuming. - Requires a
team of trained auditors. - Deals with a large amount of
information. - Only evaluates record keeping.

22. Frameworks for quality assurance
1 Maxwell (1984)
Maxwell recognized that in a society where recourses
are limited self assessment by health care professional
is not satisfactory in demonstrating the efficiency or
effectiveness of a service. The dimensions of quality he
proposed are :
Access to service
Relevance to need
Effectiveness
Equity
Social acceptance
Efficiency and economy

23. 2. Wilson (1987)
Wilson considers there to be four essential components
to a quality assurance programme. These are
Setting objectives
Activity monitoring
Quality promotion
Performance assessment
3. Long (1976)
This framework has subsequently been adopted and
developed by the ANA.

24. Impacts
Impact of ISC in
a local Hospital
Impact of ISC in
a local Nursing
educational
Institutional
Positive Impact Negative Impact

25. Critical Analysis
Strengths : ISO helps to improve and maintain the
quality of educational institutions and hospitals.
Weakness : Standards are set by the institution itself –it
may be biased.
Opportunities : Helps in professional growth
Threats : Organizational philosophy and policies may
not be considered.

26. Factors affecting Quality Assurance in Nursing Care:
1) Lack of Resources: Insufficient resources, infrastructures,
equipment, consumables, money for recurring expenses and staff
make it possible for output of a certain quality to be turned out
under the prevailing circumstances.
2) Personnel problems: Lack of trained, skilled and motivated
employees, staff indiscipline affects the quality of care.
3) Improper maintenance: Buildings and equipment‘s require proper
maintenance for efficient use. If not maintained properly the
equipment‘s cannot be used in giving nursing care. To minimize
equipment down time it is necessary to ensure adequate after
sale service and service manuals.
4) Unreasonable Patients and Attendants: Illness, anxiety, absence of
immediate response to treatment, unreasonable and
uncooperative attitude that in turn affects the quality of care in
nursing.
5) Absence of well informed population: To improve quality of
nursing care, it is necessary that the people become
knowledgeable and assert their rights to quality care. This can be
achieved through continuous educational program.

27. 6) Absence of accreditation laws: There is no organization
empowered by legislation to lay down standards in nursing and
medical care so as to regulate the quality of care. It requires a
legislation that provides for setting of a stationary accreditation
/ vigilance authority to
a) Inspect hospitals and ensures that basic requirements are
met.
b) Enquire into major incidence of negligence
c) Take actions against health professionals involved in
malpractice
7) Lack of incident review procedures: During a patient‘s
hospitalizations reveal that incidents may occur which have a
bearing on the treatment and the patients‘ final recovery? These
critical incidents may be
a) Delayed attendance by nurses, surgeon, physician
b) Incorrect medication
c) Burns arising out of faulty procedures
d) Death in a corridor with no nurse / physician accompanying
the patient etc.

28. 8) Lack of good and hospital information system: A good
management information system is essential for the
appraisal of quality of care.
a) Workload, admissions, procedures and length of stay
b) Activity audit and scheduling of procedures.
9) Absence of patient satisfaction surveys:
Ascertainment of patient satisfaction at fixed points on
an ongoing basis. Such surveys carried out through
questionnaires, interviews to by social worker,
consultant groups, and help to document patient
satisfaction with respect to variables that are
a) Delay in attendance by nurses and doctors.
b) Incidents of incorrect treatment

29. 10) Lack of nursing care records: Nursing care records are
perhaps the most useful source of information on quality of
care rendered. The records.
a) Detail of the patient condition.
b) Document all significant interaction between patient and the
nursing personnel.
c) Contain information regarding response to treatment.
d) Have the dates in an easily accessible form.
11) Miscellaneous factors:
a) Lack of good supervision.
b) Absence of knowledge about philosophy of nursing care.
c) Lack of policy and administrative manuals.
d) Substandard education and training.
e) Lack of evaluation technique.
f) Lack of written job description and job specifications.
g) Lack of in-service and continuing educational program

30. Quality assurance models
I. A system model for implementation of unit based
quality assurance
The basic components of the system are
1 Input
2 Throughput
3 Output
4 Feedback
II. A system model for implementation of unit based quality
assurance model from susan clemene diana geeber :
comprehensive family and community health nursing 3rd edition
pg.851
The basic components of the ANA model can be summarized as
follows.
i) Identify values
ii) Identify structure, process and outcome standards and
criteria
iii) Select measurement.
iv) Make interpretation
v) Identify course of action
vi) Choose action
vii) Take action
viii) Reevaluate.

31. Quality assurance process
1. Establishment of standards or criteria.
2. Identify the information relevant to criteria
3. Determine ways to collect information.
4. Collect and analyze the information.
5. Compare collected information with established
criteria.
6. Make a judgment about quality
7. Provide information and if necessary take corrective
action regarding findings of appropriate sources.
8. Determine ways to collect the information.

32. Nursing Standards
Introduction
Standards are professionally developed expressions of the range of
acceptable variations from a norm or criterion.
Avedis donabedian
Standards may be defined us benchmark of achievement which is
based on a desired level of excellence
Criteria are pre- determined elemets against which aspects of the
quality of medical service may be compared
What are nursing standards ?
All standards of practice provide a guide to the knowledge skills,
judgment and attitudes that are needed to practice safely.
They reflect a desired and achievable level of performance against
which actual performance can be compared. Their main purpose is
to promote, guide and direct professional nursing practice
(Regisstered Nurses Association of BC (2003) and the college of
nurses of ontario (2002)

33. Why are standards important ?
•Outlines what the profession expects of its members.
•Promotes guides and directs professional nursing
practice important for self assessment and evaluation of
practice by employers, clients and other stakeholders.
•Provides nurses with a framework for developing
competencies.
•Aids in developing a better understanding and respect
for the
Various and complimentary roles that nurses have
(Registered Nurses Association of BC (2003) and the
college of nurses of ontario 2002)

34. What is profession ?
Characteristics of a profession according to houle (1980)
1. Concept of mission open to change.
2. Mastery of theoretical knowledge.
3. Capacity to solve problems .
4. Use of theoretical knowledge
5. Continued seeking of self enhancement by its
members.
6. Formal training.
7. Credentialing system to certify competence
8. Creation of subculture.
9. Legal reinforcement of professional standards.
10.Ethical practice.
11.Penalties against incompetent or unethical practice.
12.Public acceptance
13.Role distinctions that differentiate professional work
from that of other vacations and permit autonomous
practice.
14.Service to society.

35. Professionalization of Nursing
Professionalization is the process by which an occupation
achieves professional status. The status of nursing as a
profession is important because it reflects the value society
Places on the work of nurses and the centratity of this work to
the good of society a profession is characterized by prolonged
education that takes place in a college or university, value,
beliefs and ethics relating to the profession are an integral part
of the educational preparation, by lifenition a professional is
autonomous in decision making and is accountable for his or
her own actions personal identification and commitment to the
profession are strong and individuals are unlikely to change
professtions in contrast an occupation is characterized by
training that may occur on the job for varying lengths of time.
The training does not incorporate as a prominent feature the
values beliefs and ethics of the occupation the workers are
supervised and ultimate accountability rests with the employer.
Thus commitmenet is not always strong and individuals often
changes jobs (Chitty 1993)

36. Professional nursing practice involves “specialized
skills essential to the performance of a unique
professional role” the two main concepts that are in the
forefront of professional nursing and its services ideal
are accountability and autonomy.
Accountability is the state of being responsible and
answerable for one’s own behavior. The sphere of a
nurse’s accountability is to self the client the employing
agency, and the profession. The standards of clinical
nursing practice by ANA and standard’s of the various
specialty nursing practices document the professional
nurse’s scope and limits of accountability. By virtue of
these standard’s society holds nurses and those under
their supervision accountable for their actions.
Autonomy in nursing is the freedom and the authority to
act independently. It implies control over one’s practice
and it applies to both decisions and actions.

37. Professional standards and nursing process
Professional standards ensure that the highest level of
quality nursing care is promoted. Excellent nursing
practice is a reflection of sound ethical standards. Client
care requires more than just the application of scientific
knowledge. A nurse must be able to think critically solve
problems and find the best solution for client’s needs to
assist clients in maintaining, regaining or improving
their health.
Nursing Profession and essential components.
Nursing is a helping, independent profession that
provides services that contribute to the health of people.
Three essential components of professional nursing are
care and co-ordination caring aspect is rational and
requires a nurse to understand the patient’s needs at a
level that permits individualization of nursing therapies.

38. Clinical, administrative and academic experts have
developed standards of nursing practice. The most
widely accepted one is American nurses association
(ANA) 2004 within this document there are standards of
professional performance and standards of practice.
Nursing as a profession
Nursing is not simply a collection of specific skills and
the nurse is not simply a person trained to perform
specific tasks. Nursing is a profession no one factor
absolutely differentials a job a profession but difference
it important in terms of how nurse practice. When one
can say a person acts “Professionally” for example we
imply that the person in conscientious in actions.
Knowledgeable in the subject and responsible to self
and others.
Standards of professional performance
The ANA standards of professional performance
describes a competent level of behavior in the
professional role, including activities related to

39. Quality of care, performance appraisul education
collegiality ethics, collaboration, research and resource
utilization this document serves as objective guidelines
for nurses to be accountable for their actions their
patient & and their peers, the standards provide a
method to assure clients that they are receiving high –
quality care, that the nurses know exactly what is
necessary to provide nursing care and that measure are
in place to determine whether the care meets the
standards.
ANA standards of professional performance.
I standards : Quality practice
Definition : the registered nurse systematically enhanced
the quality and effectiveness nursing practice.
Measurement criteria
1. Demon struke quality by documenting the application
of the nursing process in a responcible accountable and
ethical manner.

40. 2. Uses quality improvement activates to initiate changes in
nursing practice and health care delivery system.
3. Uses creativity and innovation to improve nursing care
delivery.
4. Incorporates new knowledge to initiate changes in nursing
practice if desired outcomes are not achieved.
5. Participates in quality improvement activities.
II. Standars : Education
Definition : the nurse attains knowledge and cometency that
reflect current nursing practice.
Measurement criteria
1. Participate in ongoing educational activities related to clinical
knowledge and professional issues.
2. Demonstrates commitment to life long learing.
3. Seeks experiences to maintain clinical skills.
4. Seeks knowledge and skills appropriate to the practice
setting.
5. Maintains professional records that provide evidence of
competency and lifelong learning.

41. III. Standards professional practice evaluation
Definition : The nurse evaluates one’s own nursing
practice in relation to professioanl practice standards
and guide line, relevant statutes, rules and regulations.
Measurement criteria
1. Engage in self evaluation an a regular basis.
2. Seeks contructive feedback regurding ones own
practice.
3. Takes action to achieve gouls identified during the
evaluation process.
4. Participates in systematic peer review us appropriate.
5. Practice reflects knowledge of current practice
standard’s laws and regulations.
6. Provides age appropriate care in culturally and
ethnically sensitive manner.

42. IV STANDARDS:- COLLEGIALITY
Definition: the nurse interacts with and contribute to the
professional development of peer and other health care
provider as colleagues.
MEASUREMENT CRITERIA
Shares knowledge and skill with peers and colleagues.
Provides peer with feedback regarding their practice.
Interact with peers and colleagues.
To enhance once own professional nursing practice.
Maintain compassionate and caring relationships with peers
and colleagues.
Contribute to an environment that is conductive to clinical
education nursing students as appropriate.
Contribute to a supportive and healthy work environment.

43. V STANDARDS:- COLLABORATION
Definition: the nurse collaborates with patients, family, and others in the
conduct of nursing practice.
MEASUREMENT CRITERIA
COMMUNICATE WITH THE PATIENT, SIGNIFICANT OTHERS, AND health
care providers regarding patient care and nursings role in the provision of
care.
Collaborates with patient, family and other health care providers in the
formulation of overall goals and the plan of care and in the decision related to
care and delivery of services.
Partners with other to effect change and generate positive outcome.
Document referrals, including provisions for continuity of care, as needed.
VI STANDARDS:- ETHICS
Dfinition: the nurse integrates ethical provisions in all areas of practice.
MEASUREMENT CRITERIA
Practice is guided by code of ethics for nurses with interpretive statement .
Maintains therapeutic and professional patient- nurse relationship
Deliver care in the manner of that preserves patient autonomy, dignity and
rights.
Seeks available resourced in formulating ethical decision .
Report legal, incompetent or impaired practice.
Maintain patient confidentiality within legal and regulatory parameters.

44. VII STANDARDS:- RESEARCH
Definition: the nurse integrates research findings in practice
MEASUREMENT CRITERIA
Utilize best available evidence including research findings to guide
practice decisions.
Participates in research activities as appropriates to the nurses
education and position .
Identify clinical problems suitable for nursing research
Participating in data collection
Participating in a unit, organization or community research
committee
Sharing research activities with others conductive research
Critiquing research for application to practice
Uses research findings in the development of policies, procedures,
and practice guidelines for patient care.
Incorporates research as a basis for learning.

45. VIII STANDARDS:- RESOURCE UTILIZATION
Definition: the nurse consider factors related to safety effectiveness,
cost, and impact on practice in the planning and delivery of nursing
services.
MEASUREMENT CRITERIA
Evaluate factors related to safety, effectiveness, availability and cost
when practice options would result in the same expected patient
outcome
Assists the patient and family in identifying and securing appropriate
and available services to address health related needs.
Assigns or delegates tasks as defined by the state nurse practice
acts and according to the knowledge and skills of the designated
care giver.
Assigns or delegate task based on the need and condition of the
patient, the potential for harm, the stability of the patient condition,
the complexity of the task, and the predictability of the outcome.
Assists the patient and family in becoming informed consumers
about the cost, risks, and benefits of treatment and care.s

46. IX STANDARDS:- LEADERSHIP
Definition: the nurse provides leadership in the professional practice
settings and the profession
MEASUREMENT CRITERIA
engage on team work
works to create and maintain healthy work environments.
Teach others to succeed through mentoring.
exihibits creativity and flixiblity during change .
direct coordination of care across settings and care givers.
Serves in key role in the work setting by participating on
committees councils, and administrative.
promotes advancement of the profession.
display the ability to define a clear vision, the associate goals and a
plan to implement and measure progress.
demonstrates energy excitement and a passion for quality work.
willingly accepts mistakes by self and others, thereby creating a
culture in which risk taking is not only safe, but expected.

47. STANDARDS OF CARE
THE STANDARDS OF CARE IN THE ANA NURSING: scopes and
standards of practice (2004) describes a monopetent level of
nursing care. The level of care are demonstrated through the
nursing process . the nursing process is the foundation of
clinical decision making and includes all significant action
taken by nurse in providing care to clients, within these are the
nursing responsibilities for diversity, safety, education, health
promotion, treatment, self care, and planning for the continuity
of care . standards of care are important if a legal dispute
arises over whether a nurse practiced appropriately in a
particular case.
ANA STANDARDS OF PRACTICE
ASSESSMENT
DIAGNOSIS
OUTCOME IDENTIFICATION
PLANNING
IMPLIMENTATION
EVALUATION

48. CODE OF ETHICS
Nursing has a code of ethics that defines the principles by
which nurse provide care to their clients. In addition, nurses
with interpretive statements provides a guide for carrying out
nursing responsibilities that provides for the ethical
obligations of the profession.
STANDARD NURSING CARE: AN ASSET
In order to ensure quality care the nursing care needs some
standards. Standards are the degree of excellence. The aim of
standard nursing care is to support and contribute to excellent
practice. The role of nurse is constantly changing to meet the
growing needs of health services.

49. OBJECTIVES
.Plan
.Holistic Approach
. Appropriate Diagnosis
. Realistic Goal
. Selecting Appropriate Media
. Quality Care Rater Than Quantity
. Economize Time, Material, Energy
TYPES OF STANDARD CARE
Structure – things we use
Process – things we do
Outcome – the result
CHARACTERISTICS OF STANDARD CARE
Dynamic
Reflects changes
Not static
BRIEF DESCRIPTION OF METHODS AND PROCEDURE
S – successful termination of helping relationship for client.
T – to have clear idea or conception of the distinct goal, nursing the
patient and health needs of society.
A – assertive planning
N – nature of client nursing interaction
D – directing others
A – analytical thinking
R – respect status and policies
D – data collection in accordance with goal.

50. STANDARDS
Nursing practice requires that a conceptual model for nursing be the basis for
the independent part of the practice.
ELEMENT
Nurses are required to have clear idea or conception of the distinct goal nursing,
the source of client difficulty, the focus, and modes of nursing intervention and
the expected consequences of nursing activities.
STANDARDS
Nursing practice requires the effective use of the nursing process.
ELEMENT
Nurses are required to increase the likelihood that the client will perceive the
health services experience as understandable, manageable and meaningful at
the outset. Nurses are required to ensure a successful termination of the helping
relationship.
STANDARD IN NURSING PRACTICE
Professional responsibilities
Health team members
Ethics
Policies
Conceptual
Health needs of society
Nursing intervention
Effective use of nursing process
Data collection
Diagnosis
Goal.

51. Conclusion
The expense of quality is an interactive process between
customer and provider. Quality assurance usually
focuses and material good work and service provided
effectively. Any lack in service provided causes decrease
in quality.
Summary
In quality assurance in nursing we give a short and clear
introduction about the topic and clearly define the topic.
We studied about the concept, approaches, framework
factors model. We studied about the setting standards of
quality assurance and nursing care standards.

52. BIBLIOGRAPHY
1. Avdry berman shirlee J. snyder geralyn frandsen :
Fundaments of nursing concepts process and practice 10th
edition published by pearson PP 252-253
2. Carol taylor, Carol lillis ariscilla lemone : Fundamental of
nursing the art and science of nursing core 5th Edition
published by wolters kluwer PP 328- 332
3. Caroline bunker rosdahl mary t. kowalski : Textbook of basic
nursing 9th edition published by wolters kluwer PP-23.
4. Helen Harkreader mary Ann Hogan: Fundamentals of nursing
caring and clinical Judgment 2nd edition published by
sannders PP 277-278
5. Judith M. Wilkinson Leslie. S.Treas : Fundamentals of nursing
2nd Edition volume 1 published by LISA B. Beitch PP. 133
6. Potter and perriy’s : Fundamentals of nursing 2nd edition
published by elsevier PP. 124-127.
7. Shebeer P Basheer,s yaseen khan, a concise text book of
advanced nursing practice 2nd edition published by Emmess
PP. 48-59
8. Taylor Lillis Lemone Lynn : Fundamental of nursing the art and
science of nursing care 7th edition published by wolters kluwer
PP. 317-320.

53. WEBLIOGRAPHY
1. https://www.slideshare.net/migronrubin.
2. https://www.slideshare.net/jefranklinnurse