Bronchial asthma.pptx, A clinical case study

case study

1. Case Presentation On Bronchial Asthma Sangita Thapa BNS 3 rd year

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.  

5. History Taking

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

17. Development task

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. Respiratory system

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. R ight 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. STRUCTURE OF LUNGS Each lungs is divided and described into five parts: Apex :The apex is rounded and rises into the root of the neck. Base : The base is concave and semi lunar in shape and closely associated with thoracic surface of the diaphragm. Costal surface : the costal surface is convex and is closely associated with the costal cartilage, ribs and the intercostals muscles.

25. 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 5 th ,6 th ,and 7 th thoracic vertebrae

26. 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.

27. T he 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 .

28. Functions of respiratory system supplies the body with oxygen and disposes of carbon dioxide filters inspired air produces sound contains receptors for smell rids the body of some excess water and heat It regulates acid base balance by excreting co2 from the body Mechanism of respiration : inspiration , expiration , pause .

29. 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)

30. 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

31. Pause After each inspiration and expiration there is a small rest called respiratory pause. Then continue inspiration and expiration

32. 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.

33. 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).

34. Types of Bronchial Asthma Two type : Allergic or extrinsic asthma Non- allergic or intrinsic asthma In most cases, it is mixed type.

35. 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.

36. 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.

37. 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

38. 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  

39. Broncho constriction (bronchospasm) & increased production   SOB/Obstruction of airway Hypoxia,Wheezing .

40. 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

41. 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)

42. Laboratory Test Total leukocyte count Done Differential count Done

43. Laboratory Investigations Investigations Findings Normal value Hemoglobin 16.1gm/dl 12-16gm/dl (M) 14-18gm/dl (Fe) TLC 12,700cells/cu mm 4,000-10,000cells/cu mm DLC Neutrophil Esinophil Basophil Monocyte Lymphocyte ESR 90% 01% 00% 03% 20% 17 mm/ hr 45-69% 2-6% 0-1% 2-10% 20-40% Male(0-7mm/ hr ) Female(0-15mm/ hr )

44. Investigations Findings Normal value S sodium S potassium S creatinine Urea 136.6meq/l 4.97meq/l 0.8mg/dl 20mg/dl   135-145meq/l 3.5-4.5meq/l 0.4-1mg/dl 10-40mg/dl   RBS 158mg/dl 79-140mg/dl

45. Medical Management

46. 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

47. 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

48. Drug Card

49. 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 .

50. 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)

51. 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.

52. 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.

53. 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.

54. 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

55. Complications Status asthmatics Respiratory failure Atelectasis Pneumonia Emphysema Severe hypoxemia Pneumothorax

56. 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

57. 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.

58. Progress of my patient Admission day 2074/11/10 1 st day 2074/11/11 2 nd day 2074/11/12 3 rd day 2074/11/13 4 th day 2074/11/14 Vital sign Blood pressure Pulse Temperature Respiration Diet 140/100mm/hg 64b/m 100⁰F 28/m Liquid diet 140/90mm/hg 72b/m 99.4⁰F 28/m Liquid diet 130/80mm/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 investigation report Continu oxygen, chest physiotherapy CST CST and plan for ward shift, O2 intermittent CST

59. 5 th day 2074/11/15 6 th 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.

60. 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

61. 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 .  

62. 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.

63. 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.

64. 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. .  

65. 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

66. 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 : Kept the patient in comfortable position. Assessed respiratory rate, pattern and depth position for breathing. Administered humidified oxygen. Elevated head of the bed. Provided chest physiotherapy.

67. Evaluation: After 2 hour of nursing intervention patient was able to breath in regular pattern and breathing rate was 26 b/min.

68. 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.

69. 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.

70. 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: Assessed nutritional status. Took history of nutritional status. Maintained oral hygiene. Provided patient’s food preference within dietary restriction. Explained rational for dietary restrictions. Offered small frequent meal in pleasant environment.

71. 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.

72. 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: Assessed past pattern of sleep. Documented sleeping & wakeful behaviors. Advised patient to increased day activities & discourage day naps. Suggested use of soporifics such as milk before going to bed. Recommended environment conductive sleep ( quite environment, ventilation, darkness).

73. Evaluation: Patient verbalized having improved sleeping pattern at night .

74. 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.

75. 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.

76. 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

77. Following measures were taken for stress management in my patient :- Build a good rapport with the patient and family members . 79

78. Gave complete orientation about ward, routine of wards, rules and regulations . 80

79. 81 Thoroughly explained about disease condition, its management and modification therapies etc.

80. Provided opportunities to express her feelings with family members . 82

81. Encouraged patient in self-care and also motivated family members to assist her in daily living activities and other works . 83

82. Advised to make coping strategies:-positive thinking, set priorities and limits and develops sense of humor . 84 Set priorities and limits Develop sense of humor

83. Advised for balanced and nutritious diet. 85

84. Reassurance and emotional support. 86

85. AVIODANCE OF ALLERGENS AND USE OF MASK FOR THE PREVENTION OF DUST AND POLLUTION

86. DIVERSIONAL THERAPY

87. TALK THERAPY

88. TOUCH THERAPY

89. FAMILY THERAPY

90. Music therapy

91. Gadgets used in my patient

92. DISCHARGE TEACHING AND HEALTH EDUCATION 94

93. 1. Rest and sleep 95

94. 2 . Nutritional diet 96

95. 3.Avoid eating fried, spicy, oily and red meat 97

96. 4. Sustain from alcohol, smoking, tobacco and drugs 98

97. 5. Regular yoga and exercise but to avoid unnecessary exertion. 99

98. 6. Relax and avoid stress 100

99. 7 . Regular health checkup 101 Blood pressure monitoring

100. 8 .Medication and its side effects. 102

101. 8.Follow up . 103 9 .

102. 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.

103. 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.

104. REFERENCES Brunner and shuddarth(2012), Text book of medical and surgical nursing, 12 th edition, walters kluwer(India) pvt. Ltd, New Delhi. Rai L. (2011), Nursing concept theory and principle,2 nd edition , Nabin k. Rai, Kathmandu. Smeltzer, c and et.al (2010). Ross and Wilson(1988), Anatomy and Physiology, 6 th edition, longman group FE Ltd. Tripathi K.D.(2008),essential of medical pharmacology,6 th edition, jayapee brothers medical publisher private LTD New Delhi Tuitui R. (2005), pocket book of drugs,2 nd edition, Makalu books and stationers, Putalisadak Mandal GN 2012,Text book of adult health, 1 st edition, Makalu publication, dillibazar, Kathmandu www.wikipedia.com/prognosis/complications/anatomy and physiology

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