[CPCR] CARDIOPULMONARY CEREBREAL RESUSCITATION PROCEDURES

Cardiopulmonary cerebral resuscitation (CPR) is a life-saving technique used to restore circulation and breathing to individuals who have experienced sudden cardiac arrest or other life-threatening emergencies. CPR combines rescue breathing (mouth-to-mouth) and chest compressions to temporarily pump enough blood to the brain until specialised treatment is available. The technique is used to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest.

1. ASSIGNMENT
ON
CPCR

2. CARDIOPULMONARY CEREBRAL RESUSCITATION
Definition of Cardiac arrest:
It is loss of cardiac function, breathing and loss of consciousness.
Diagnosis of cardiac arrest (TRIAD):
1)Loss of consciousness.
2)Loss of apical & central pulsations (carotid, femoral).
3)Apnea.
TYPES (FORMS) OF CARDIAC ARREST:
1)Asystole (Isoelectric line)
Check that all leads are attached.
 Adrenaline 1 mg IV every 4 mins (2 cycles) (until a shockable rhythm is achieved).
2)Ventricular fibrillation (VF)
Bizarre irregular waveform.
No recognizable QRS complexes.
Random frequency and amplitude.
Coarse / fine.
Exclude artifact:
 movement
 electrical interference

3. 3)Pulseless Ventricular tachycardia (VT)
Broad bizarre-shaped complexes.
 Rapid rate: 120-250/min.
 Regular.
Precordial thump: Rapid treatment of a witnessed and monitored VF/VT cardiac
arrest.
4)PEA: pulseless electrical activity

Exclude / treat reversible causes.
 Adrenaline 1 mg IV every 4 mins (2 cycles) (until a shockable rhythm is reached).
Causes of cardiac arrest (6 H & 4 T):
1)H ypoxia.

4. 2)H ypotension.
3)H ypothermia.
4)H ypoglycemia.
5)Acidosis (H
+
).
6)H ypokalemia (electrolyte disturbance).
1)Cardiac Tamponade.
2)T ension pneumothorax.
3)T hromboembolism (pulmonary, coronary).
4)T oxicity (eg. digoxin, local anesthetics, TCA, insecticides).
DEFINITION OF CPCR:
Cardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial
ventilation to maintain circulatory flow and oxygenation during cardiac arrest.
PURPOSES:
•To maintain an open and clear airway (A).
•To maintain breathing by external ventilation (B).
•To maintain Blood circulation by external cardiac massages (C).
•To save life of the Patient.
•To provide basic life support till medical and advanced life support arrives.
DIAGNOSIS OF CARDIO PULMONARY ARREST:
CARDIAC ARREST:
1.Absence of of pulse in major arteries (carotid or femoral in older children and femoral
or brachial in infants as carotid is difficult to palpate due to short neck.)
2.Absence of Heart Sounds on Auscultation.

5. 3.Asystole/ventricular fibrillation on ECG.
RESPIRATORY ARREST:
Absence Of Respiration On Looking (Absent Chest Movement), Listening (Absent Air Flow
On Bringing Ears In Front Of Mouth Or Nose).
BASIC LIFE SUPPORT(BLS):
It is life support without the use of special equipment.
ADVANCED CARDIAC LIFE SUPPORT(ACLS):
It is life support with the use of special equipment (eg. Airway, endotracheal tube,
defibrillator).
3 S steps before the initiation of resuscitation for management of a collapsed patient:
1)Ensure your own Safety.
2)Check the level of responsiveness by gently shaking the patient and Shouting: “are
you alright?”
3)Shout for help.
4)Then check for carotid pulsations.
5)Apnea (cessation of respiration) is confirmed by:
6)Look: to see chest wall movement.Seesaw (paradoxical) movement of the chest wall
indicates airway obstruction.
7)Listen: to breath sounds from the mouth.
8)Feel: air flow.
9) For at least 10 seconds

6. There are 4 cornerstones for optimising the outcome following cardiac arrest:
Early recognition & call for help: to prevent cardiac arrest.
Early CPR (with minimal interruptions): to buy time.
Early defibrillation: to restart the heart.
Post resuscitation care: to restore quality of life & minimize neurological insult.
Life support includes A B C:
A= Airway (and cervical spines)
B= Breathing
C= Circulation
Airway:
Loss of consciousness often results in airway obstruction due to loss of tone in the muscles
of the airway and falling back of the tongue.
►(A) Basic techniques for airway patency:
1) Head tilt , chin lift : one hand is placed on the forehead and the other on the chin
the head is tilted upwards to cause anterior displacement of the tongue.

7. 2) Jaw thrust:
3) Finger sweep: Sweep out foreign body in the mouth by index finger (in unconscious pt
only. This is NOT advised in a conscious or convulsing patient).

8. 4) Heimlich manoeuvre: if the pt is conscious or the foreign body cannot be removed by a
finger sweep. It is done while the pt is standing up or lying down. This is a subdiaphragmatic
abdominal thrust that elevates the diaphragm expelling a blast of air from the lungs that
displaces the foreign body. In infants his can be done by a series of blows on he back and
chest thrusts.


Cervical Spines:

9. ► Special care must be taken during airway management for the cervical spines. Any
polytraumatised patient may sustain injury to the cervical spines, and any rough
manipulation may result in cervical spinal cord injury and subsequent quadriplegia.
► Thus in any polytraumatised patient cervical in-line stabilization must be routinely
performed during transport and airway management.
► This can be done by a cervical collar.
► And the patient should be transported by specially trained medical personnel as one unit.
(B) Advanced techniques for airway patency:
1) Face Mask
Signs of successful seal and ventilation include:
- Foggy mask.
- Rising chest.
Advantages: Easy. Does not require skilled personnel (paramedics).
Disadvantages: Stomach inflation. Not protective against regurgitation & aspiration of
gastric contents.
2) Oropharyngeal airway:
Advantages: Easy. Does not require highly skilled personnel (can be used by paramedics).
Disadvantages: Not protective against regurgitation & aspiration of gastric contents. Poorly
tolerated by conscious pts (gag).

10. 3)Nasopharyngeal airway:
Lubricated and inserted throught the nose.
► Better tolerated in conscious patients.
► Contraindicated: in anti-coagulated patients and fractured skull base.
► Disadvantages: Not protective against regurgitation & aspiration of gastric contents.
5)Laryngeal mask (LMA):
Available in a variety of pediatric and adult sizes.
► Advantages: Easy. Does not require highly skilled personnel (can be used by
paramedics).
► Disadvantages: Stomach inflation. Not protective against regurgitation & aspiration of
gastric contents.

11. 5) Endotracheal tube
► Advantages: Ensures proper lung ventilation. No gastric inflation. No regurgitation or
aspiration of gastric contents.
► Disadvantages: Requires insertion by highly skilled personnel.
6)Combitube:
► Advantages: Easy to use. Does not require highly skilled personnel (can be used by
paramedics).

12. 7)Cricothyrotomy (Surgical Airway):
It is done either by a commercially available cannula in a specialized cricothyrotomy
set or a large bore IV cannula 12-14 gauge.
Is done in case of difficult endotracheal intubation.
Nu-trake canula is specially designed to allow ventilation by a self-inflating bag
(AMBU)
An IV canula needs a special connection to a high pressure source to generate
sufficient gas flow (trans-tracheal jet ventilation).

13. 8)Tracheostomy (Surgical Airway):
B = Breathing:

Basic techniques include:
1) Mouth to mouth breathing: with the airway held open, pinch the nostrils closed, take a
deep breath and seal your lips over he patients mouth. Blow steadily into the patients’ mouth
watching the chest rise as if the patient was taking a deep breath.
2) Mouth to nose breathing: seal the mouth shut and breathe steadily though the nose.
3) Mouth to mouth and nose: is used in infants and small children.

14. ►Expired air contains 16% O2 so supplemental 100% O2 should be used as soon as possible.
►Successful breathing is achieved by delivery of a tidal volume of 800-1200 ml in adults at
a rate of 10-12 breaths/min in adults.
(B) Advanced techniques include:
1) Self-inflating resuscitation bag (Ambu bag):
When used without a source of O2 (room air) gives 21% O2.
When connected to a source of O2 (10-15 L/min) gives 45% O2.
If a reservoir bag is added it can give up to 85% O2.
2) Mechanical ventilator in OR or in ICU:
Expired air = 16% O2
Ambu Bag (room air) = 21% O2
Ambu bag + O 2 (10-15L) = 45% O2
Ambu Bag + O 2 + Reservoir bag = 85%
C = Circulation:
(A) Chest compressions (BLS & ACLS).
(B) IV access (ACLS).
(C) Defibrillation (ACLS)
1) Chest compressions (cardiac massage):
The human brain cannot survive more than 3 minutes with lack of circulation. So chest
compressions must be started immediately for any patient with absent central pulsations.

15. Technique of chest compressions:
Pt must be placed on a hard surface (wooden board).
The palm of one hand is placed in the concavity of the lower half of the sternum 2
fingers above the xiphoid process. (AVOID xiphisternal junction → fracture &
injury).
The other hand is placed over the hand on the sternum.
Shoulders should be positioned directly over the hands with the elbows locked
straight and arms extended.
Sternum must be depressed 4-5 cm in adults, and 2-4 cm in children, 1-2 cm in
infants
Must be performed at a rate of 100-120/min
During CPR the ratio of chest compressions to ventilation should be as follows:
Single rescuer = 30:2
In the presence of 2 rescuers chest compressions must not be interrupted for
ventilation.
Chest compressions in infants (0-12 months):
(B) IV access
A pre-existing central venous line is ideal in CPR, but if it is not present it will be
time-consuming. Drug administration must be followed by 10 ml IV fluid bolus.

16. Peripheral IV line is associated with significant delay between drug administration
and delivery to the heart, since peripheral blood flow is drastically reduced during
resuscitation. So drug administration must be followed by 20 ml IV fluid bolus in
adults and elevation of the limb to ensure delivery to the central circulation.
Also in cases of difficult venous access intraosseous drug and fluid administration
can be performed.
(C) Defibrillation: Adult ALS algorithm:
Defibrillation:
Position of Paddles:
One paddle is placed in the right infraclavicular region, while the other is placed in
the left 5
th
-6
th
intercostal space anterior axillary line.

17. Alternatively antero-posterior position may be used: one paddle is placed in the left
infrascapular region while the other is placed in the left 5
th
-6
th
intercostal space
anterior axillary line.
Precautions:
Make sure the paddles have conducting gel on them: (Why??)
1- The electricity will not be properly transmitted to the chest wall without it.
2- Even with the gel these paddles will often cause a second-degree skin burn.
Make sure that you have cleared the bed: make sure that no one is in contact with
the bed otherwise this person may be electrocuted and develop VT or VF.
Hold the paddles down firmly: 25 pounds of pressure (= 11 kg)!!
Chest compressions must be continued for 2 minutes after DC shock before
reassessment of cardiac rhythm.
Complications of defibrillation: skin burn, injury to myocardium and elevation of
cardiac enzymes, electrocution of person in contact with the bed.
Drugs used in CPR:
1)Adrenaline:
- Given as a vasopressor α-1 effect (not as an inotrope).
- Dose: 1 mg (0.01 mg/kg) IV every 4 minutes (alternating cycles) while continuing
CPR.
Given:
1) Immediately in non-shockable rhythm (non-VT/VF).
2) In VF or VT given after the 3
rd
shock.
Repeated: in alternate cycles (every 4 minutes).
-Once adrenaline → ALWAYS adrenaline.

18. 2)Amiodarone:
- Dose: 300 mg IV bolus (5 mg/kg).
- Given: in shockable rhythm after the 3
rd
shock.
- If unavailable give lidocaine 100 mg IV (1-1.5 mg/kg).
3) Vasopressin (ADH): 40 IU single dose once.
4)Magnesium:
- Dose: 2 g IV.
-Given:
1- VF / VT with hypomagnesemia.
2- Torsade de pointes.
3- Digoxin toxicity.
5)Calcium:
Dose: 10 ml of 10% Calcium chloride IV.
Indications: PEA caused by: hyperkalemia, hypocalcemia, hypermagnesemia, and overdose
of calcium channel blockers.
Do NOT give calcium solutions and NaHCO3 simultaneously by the same route.
6)IV Fluids:
Infuse fluids rapidly if hypovolemia is suspected.
Use normal saline (0.9% NaCl) or Ringer’s solution.
Avoid dextrose which is redistributed away from the intravascular space rapidly and
causes hyperglycemia which may worsen neurological outcome after cardiac arrest.
Dextrose is indicated only if there is documented hypoglycemia.
Thrombolytics:

19. Fibrinolytic therapy is considered when cardiac arrest is caused by proven or
suspected acute pulmonary embolism.
If a fibrinolytic drug is used in these circumstances consider performing CPR for at
least 60-90 minutes before termination of resuscitation attempts.
Eg: Alteplase, tenecteplase (old generation: steptokinase).
7)Sodium bicarbonate:
► Used in:
1- Severe metabolic acidosis (pH < 7.1)
2- Life-threatening hyperkalemia.
3- Tricyclic antidepressant overdose.
► Dose: (half correction)
1mEq/Kg stat and 0.5 mEq/Kg every 10 min
Avoid its routine use due to its complications:
1- Increases CO2 load:
2- Inhibits release of O2 to tissues.
3- Impairs myocardial contractility.
4- Causes hypernatremia.
5- Adrenaline works better in acidic medium.
8)Atropine:
Its routine use in PEA and asystole is not beneficial and has become obsolete.
Indicated in: sinus bradycardia or AV block causing hemodynamic instability.
Dose: 0.5 mg IV. Repeated up to a maximum of 3 mg (full atropinization).
9)Glucose:
Indication: Hyoglycemia,Maintain Temperature,Shock

20. Dose:0.5mg-1g/kg Iv
10)Nalaxone:
Indication: Narcotic Overdose Or Poisoning And New Born Resuscitation.
dose:0.1mg/kg
Monitoring:
Pulse should be palpable and chest expansion should be seen during effective cpr, blood
pressure, SPO2, ETCO2, ABG, should be monitored during and soon after CPR.
Termination of CPR:
If asystole persists for >10 minutes after CPR has been performed,ventricular fibrillation
eliminated,successful endotracheal intubationaccomplished and confirmed,adequate
ventilation provided and appropriate medications given.
NURSING ASSESSMENT AND CARE
A-AIRWAY
Unconscious patient
In the unconscious patient, the priority is airway management, to avoid a preventable cause
of hypoxia. Common problems with the airway of patient with a seriously reduced level of
consciousness involve blockage of the pharynx by the tongue, a foreign body, or vomit.
At a basic level, opening of the airway is achieved through manual movement of the head
using various techniques, with the most widely taught and used being the "head tilt — chin
lift", although other methods such as the "modified jaw thrust" can be used, especially where
spinal injury is suspected, although in some countries, its use is not recommended for lay
rescuers for safety reasons.

21. Higher level practitioners such as emergency medical service personnel may use more
advanced techniques, from oropharyngeal airways to intubation, as deemed necessary
Conscious patients
In the conscious patient, other signs of airway obstruction that may be considered by the
rescuer include paradoxical chest movements, use of accessory muscles for breathing,
tracheal deviation, noisy air entry or exit, and cyanosis.
Once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there
needs to be a circulation to deliver it to the rest of the body.
B-BREATHING
Unconscious patients
In the unconscious patient, after the airway is opened the next area to assess is the patient's
breathing, primarily to find if the patient is making normal respiratory efforts. Normal
breathing rates are between 12 and 30 breaths per minute, and if a patient is breathing below
the minimum rate, then in current ILCOR basic life support protocols, CPR should be
considered, although professional rescuers may have their own protocols to follow, such
as artificial respiration.
Rescuers are often warned against mistaking agonal breathing, which is a series of noisy
gasps occurring in around 40% of cardiac arrest victims, for normal breathing.
If a patient is breathing, then the rescuer will continue with the treatment indicated for an
unconscious but breathing patient, which may include interventions such as the recovery
position and summoning an ambulance.
Conscious or breathing patients
In a conscious patient, or where a pulse and breathing are clearly present, the care provider
will initially be looking to diagnose immediately life-threatening conditions such as
severe asthma, pulmonary edema or haemothorax. Depending on skill level of the rescuer,
this may involve steps such as:
Checking for general respiratory distress, such as use of accessory muscles to breathe,
abdominal breathing, position of the patient, sweating, or cyanosis

22. Checking the respiratory rate, depth and rhythm - Normal breathing is between 12
and 20 in a healthy patient, with a regular pattern and depth. If any of these deviate from
normal, this may indicate an underlying problem (such as with Cheyne-Stokes
respiration)
Chest deformity and movement - The chest should rise and fall equally on both sides,
and should be free of deformity. Clinicians may be able to get a working diagnosis from
abnormal movement or shape of the chest in cases such as pneumothorax or haemothorax
Listening to external breath sounds a short distance from the patient can reveal
dysfunction such as a rattling noise (indicative of secretions in the airway)
or stridor (which indicates airway obstruction)
Checking for surgical emphysema which is air in the subcutaneous layer which is
suggestive of a pneumothorax
Auscultation and percussion of the chest by using a stethoscope to listen for normal
chest sounds or any abnormalities
Pulse oximetry may be useful in assessing the amount of oxygen present in the blood,
and by inference the effectiveness of the breathing
C-CIRCULATION
Non-breathing patients
Circulation is the original meaning of the 'C' as laid down by Jude, Knickerbockers’ & Safar,
and was intended to suggest assessing the presence or absence of circulation, usually by
taking a carotid pulse, before taking any further treatment steps.
In modern protocols for lay persons, this step is omitted as it has been proven that lay
rescuers may have difficulty in accurately determining the presence or absence of a pulse,
and that, in any case, there is less risk of harm by performing chest compressions on a beating
heart than failing to perform them when the heart is not beating. For this reason, lay rescuers
proceed directly to cardiopulmonary resuscitation, starting with chest compressions, which is
effectively artificial circulation. In order to simplify the teaching of this to some groups,
especially at a basic first aid level, the C for 'Circulation' is changed for meaning 'CPR' or
'Compressions'
It should be remembered, however, that health care professionals will often still include a
pulse check in their ABC check, and may involve additional steps such as an
immediate ECG when cardiac arrest is suspected, in order to assess heart rhythm.

23. Breathing patients
In patients who are breathing, there is the opportunity to undertake further diagnosis and,
depending on the skill level of the attending rescuer, a number of assessment options are
available, including:
Observation of colour and temperature of hands and fingers where cold, blue, pink,
pale, or mottled extremities can be indicative of poor circulation
Capillary refill is an assessment of the effective working of the capillaries, and involves
applying cutaneous pressure to an area of skin to force blood from the area, and counting
the time until return of blood. This can be performed peripherally, usually on a fingernail
bed, or centrally, usually on the sternum or forehead
Pulse checks, both centrally and peripherally, assessing rate (normally 60-80 beats per
minute in a resting adult), regularity, strength, and equality between different pulses
Blood pressure measurements can be taken to assess for signs of shock
Auscultation of the heart can be undertaken by medical professionals
Observation for secondary signs of circulatory failure such as edema or frothing from
the mouth (indicative of congestive heart failure)
ECG monitoring will allow the healthcare professional to help diagnose underlying heart
conditions, including myocardial infarctions
ABCD
There are several protocols taught which add a D to the end of the simpler ABC (or DR
ABC). This may stand for different things, depending on what the trainer is trying to teach,
and at what level. It can stand for:
Defibrillation — The definitive treatment step for cardiac arrest
Disability or Dysfunction — Disabilities caused by the injury, not pre-existing conditions
Deadly Bleeding
(Differential) Diagnosis
Decompression

24. ABCDE
Additionally, some protocols call for an 'E' step to patient assessment. All protocols that use
'E' steps diverge from looking after basic life support at that point, and begin looking for
underlying causes. In some protocols, there can be up to 3 E's used. E can stand for:
Expose and Examine — Predominantly for ambulance-level practitioners, where it is
important to remove clothing and other obstructions in order to assess wounds.
Environment — only after assessing ABCD does the responder deal with
environmentally-related symptoms or conditions, such as cold and lightning.
Escaping Air — checking for air escaping, such as through a sucking chest wound,
which could lead to a collapsed lung.
Elimination
Evaluate — Is the patient "time-critical" and/or does the rescuer need further assistance.
ABCDEF
An 'F' in the protocol can stand for:
Fundus — relating to pregnancy, it is a reminder for crews to check if a female is
pregnant, and if she is, how far progressed she is (the position of the fundus in relation to
the bellybutton gives a ready reckoning guide)
Family (in France) — indicates that rescuers must also deal with the witnesses and the
family, who may be able to give precious information about the accident or the health of
the patient, or may present a problem for the rescuer.
Fluids — A check for obvious fluids (blood, cerebro-spinal fluid (CSF) etc.)
Fluid resuscitation
Final Steps— Consulting the nearest definitive care facility
ABCDEFG
A 'G' in the protocol can stand for
Go Quickly! — A reminder to ensure all assessments and on-scene treatments are
completed with speed, in order to get the patient to hospital within the Golden Hour

25. Glucose — The professional rescuer may choose to perform a blood glucose test, and this
can form the 'G' or alternately, the 'DEFG' can stand for "Don't Ever Forget Glucose
PROCEDURE FOR RECOVERY POSITION
Any unconscious victim should be placed in the recovery position. This position prevents the
tongue from blocking the throat and because the head is slightly lower than the rest of the
body, it allow liquid to drain from the mouth, reducing the risk of casualty inhaling stomach
contents.
Kneeling besides the victim, open her/his airway by tilting the head or lifting the chin.
Straighten his or her leg. Place the arm nearest you out at right angles to her or his
body, elbow bent and with the hand palm uppermost.
Bring the arm from you across the chest, and hold the hand, palm outwards, against
the victim’s nearer cheek.
With the other hand grasp the thigh further from you and pull the knee up keeping the
foot flat on the ground
Keeping her or his hand pressed against her or his cheek, pull, at the thigh to roll the
victim towards you and on to her side.
Tilt the head back to make sure the airway remains open, adjust the hand under the
cheek, if necessary so that the head stays in this tilted position.
Adjust the upper leg if necessary, so that both the hip and the knee are bent at right
angles
Dial for an ambulance (108). Check breathing and pulse frequently while waiting for
help to arrive.
POSSIBLE COMPLICATIONS OF CPR:
1)Rib fractures
2)Fracture sternum
3)Rib separation
4)Pneumothorax

26. 5)Hemothorax
6)Lung contusions
7)Liver lacerations
8)Fat emboli
9)Hiv, hepatitis
10)Infections
11)Coronary vessel injury
12)Diaphragm injury
13)Hemopericardium
14)Interference with ventilation
15)Spleen injury
16)Myocardial injury
NURSING MANAGEMENT OF CPR:
1)Maintains airway patency with use of airway adjuncts as required (suction, high flow
oxygen with O2 or bag valve mask ventilation).
2)Assist with intubation and securing of ETT
3)Inserts gastric tube and/or facilitates gastric decompression post intubation as
required.
4)Assists with ongoing management of airway patency and adequate ventilation

27. 5)Supports less experienced staff by coaching/guidance e.g. drug preparation
6)If a shockable rhythm is present (VF/VT) ensure manual defibrillator pads are applied
and connected.
7)If CPR is in progress, prepare and independently double check and label 3 doses of
adrenaline
8)Prepare and administer IV fluids
9)Document medications administered (including time)
CONCLUSION:
CPR is an emergency procedure which is attempted in an effort to return life to a person in
cardiac arrest. It is indicated in those who are unresponsive with no breathing or only gasps.
It may be attempted both in and outside of a hospital. CPR alone is unlikely to restart the
heart; its main purpose is to restore partial flow of oxygenated blood to the brain and heart. It
may delay tissue death and extend the brief window of opportunity for a successful
resuscitation without permanent brain damage
Bibliography:
1.Harvey grant,Robert M emergency care 1
st
ed. Washington DC Robert JB Rady
publisher 2002.
2.Sandra MN Manual of nursing practice 7
th
ed Philadelphia:Lippincott.2001
3.Annamma Jacob.Text book of clinical procedures 2
nd
ed.New Delhi JayPee 2003.
4.Black JM, Jane HH, Medical surgical nursing Vol 2. 7th
ed.Saunders:Missouri:2005
5.Smeltzer and Bare Brunner and Suddarths “Textbook of surgical nursing 10
th
ed:
Lippincott: Philadelphia.2004.

28. 6.Jean A Proehl “Emergency nursing procedures” 3
rd
ed.Saunders:NewYork
REFERENCES
JOYCE M...BLACK, Jane Hokinson Hawks, Medical Surgical Nursing, “Clinical
management for positive outcome”, Elsevier publication, seventh edition, volume
1st
LEWIS HEITKEMPER DIRKSEN (2008 ). Medical-surgical nursing. 7
th
edition Mosby
Elsevier publications.usa.
ROCHELLE LB, MARYBETH .;( 1993) American association of critical care nurses,
procedure manual for critical care. Philadelphia: WB Saunders Company.
SUZANNE.C.SMELTZER , Brinda.G.Bare, “Brunner and Siddhartha’s Text Book of
Medical Surgical Nursing”, Lippincott publication, ninth edition, volume
1st