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OBJECT
1. 3 Define
IVS DEFINITION
mts the term Lumbar puncture (or LP, and colloquially known as a spinal tap )is the
lumbar insertion of a needle in to a lumbar region of the spine , in such a manner
puncture that the needle enters the lumbar subarachnoid space of the spinal canal
below the level of the spinal cord, so that the cerebrospinal fluid can be
withdrawn or a substance can be therapeutically or diagnostically injected.

RELEVANT ANATOMY
2. 4 Describe
The lumbar spine consists of 5 moveable vertebrae numbered L1-L5.The
mts 1 anatomy
lumbar vertebrae have a vertical height that is less than their horizontal
of
diameter. They are composed of the following 3 functional parts:
lumbar
spine  The vertebral body, designed to bear weight
 The vertebral (neural) arch, designed to protect the neural elements
 The bony processes (spinous and transverse), which function to
increase the efficiency of muscle action.
3 2 Explain PURPOSES
mts the
Diagnostic purposes
purposes
of  To rule out potential life-threatening conditions (e.g., bacterial
lumbar meningitis or subarachnoid hemorrhage),
puncture  CSF fluid analysis can also aid in the diagnosis of various other
conditions (e.g., demyelinating diseases and carcinomatous
meningitis).
Therapeutic purposes (e.g., treatment of pseudotumor cerebri).
1. To administer spinal anesthesia before surgery in the lower half of the
body.
2. To administer medication into the spinal canal as in the case of
2 meningitis.
3. To remove fluid(CSF, blood, pus etc.) contained in the subarachnoid
space , thereby reduce the ICP, if it is dangerously high.
4. To remove sample of CSF for laboratory examinations in order to
diagnose diseases.
5. To measure pressure of the CSF and to determine whether the lumbar
subarachnoid space is in communication with the ventricles of brain.
6. To remove CSF and to replace with air, oxygen or radio opaque
substance for diagnostic X-rays in order to locate tumors or other
brain disorders.
4 2 List out
mts the
indicatio INDICATIONS
ns of Diagnostic
lumbar
puncture  Suspicion of meningitis
 Suspicion of subarachnoid hemorrhage (SAH)
 Suspicion of central nervous system (CNS) diseases such as Guillain-
Barré syndrome and carcinomatous meningitis
 Therapeutic relief of pseudotumor cerebri

Therapeutic

 To inject antibiotics or chemotherapy medication into the CSF.

3
o Intrathecal drug administration- injection 50 to 100mg in
spinal arachnoiditis, tuberculous meningitis to prevent late fibrotic
strictures, Injection crystalline penicillin in pyogenic meningitis,
injection methotrexate in acute lymphatic leukemia , CNS
prophylaxis.
Aesthetic :
o Injection of lignocaine 50mg and injection bupivacaine 1% in
spinal anesthesia
5 3 Enumera
CONTRAINDICATIONS
mts te the
contraind Absolute contraindications for lumbar puncture are
ications
for  the presence of infected skin over the needle entry site and
 lumbar  the presence of unequal pressures between the supra tentorial and
puncture infratentorial compartments.
The latter is usually inferred from the following characteristic findings on
computed tomography (CT) of the brain:

 Midline shift
 Loss of suprachiasmatic and basilar cisterns
 Posterior fossa mass
 Loss of the superior cerebellar cistern
 Loss of the quadrigeminal plate cistern

Relative contraindications for lumbar puncture include the following:

4  Increased intracranial pressure (ICP)

 Coagulopathy
 Brain abscess

Indications for performing brain CT scanning before lumbar puncture in

patients with suspected meningitis include the following:

 Patients who are older than 60 years

 Patients who are immunocompromised
 Patients with known CNS lesions
 Patients who have had a seizure within 1 week of presentation
 Patients with an abnormal level of consciousness
 Patients with focal findings on neurologic examination
 Patients with papilledema seen on physical examination, with clinical
 suspicion of an elevated ICP
6 2 Determine
mts the
articles
TECHNICAL CONSIDERATIONS
needed
for Equipment : A spinal or lumbar puncture tray should include the following
lumbar items:
puncture
 Mackintosh drapes and towel
 Sponge holding forceps
 Kidney tray or plastic bag
 Mask, apron
 Gloves , gown, mask
5  Sterile dressing
 Sterile gloves

 Sterile drape
 Antiseptic solution with skin swabs
 Lidocaine 1% without epinephrine
7 3 Train  Syringe, 3 mL
mts them to  Needles, 20 and 25 gauge
prepare  Spinal needles, 20 and 22 gauge
the
 Three-way stopcock
patient
 Manometer
for
 Four plastic test tubes, numbered 1-4, with caps with requisition forms
lumbar
 Syringe, 10 mL (optional)
puncture
 PREPARATION OF THE PATIENT

 Explain the procedure

 Obtain consent.
 Warn the patient that any movement during the procedure may cause
injury to the spinal cord and its nerves.
 Check the vital signs before sending the patient to the operation room
and record the same.
 prepare the skin as for a surgical procedure.
 put on clean and loose garments.
 Arrange the articles.
 Drape the patient properly and protect the bed with mackintosh and
8 2 Describe
towel.
mts 6 the steps
 Provide a stool for the doctor to sit comfortably.
involved
 The nurse should stand near the patient throughout the procedure
in lumbar
observing his general condition and maintaining the desired position.
puncture

PROCEDURE

STEPS RATIONALE
N
O
1 Position the patient correctly To increase the space between the vertebrae so
that the needle can be inserted more easily.
2 Prepare the skin as for a surgical To prevent infection.
procedure
3 Insert the needle between the second and To avoid spinal cord injury.
 third or between the third and fourth
lumbar vertebrae.
4 Remove the stilette when the needle is To attach the manometer.
entered the sub arachnoid space.

5 Attach the three way adapter with the To monitor the spinal fluid pressure.
manometer filled with normal saline to
the needle.
6 The patient is asked to relax as much as To get a stabilized pressure.
possible.
7 About 2 to 3 ml of CSF is allowed to To sent to the laboratory for diagnostic purpose.
drip into each of 3 sterile test tubes and
7
then withdraw the needle.
8 Seal the puncture wound. To prevent infection and leakage of the CSF.

9 2 Explain PATIENT PREPARATION BY POSITIONING

mts
how to Local anesthesia is employed for lumbar puncture.
prepare
The patient is placed in the lateral recumbent position with the hips,
the
patient knees, and chin flexed toward the chest so as to open the interlaminar
schedule spaces. A pillow may be used to support the head.
d for
The sitting position may be a helpful alternative, especially in obese
lumbar
puncture patients, because it makes it easier to confirm the midline. In order to
open the interlaminar spaces, the patient should lean forward and be
supported by a Mayo stand with a pillow on it, by the back of a stool, or
 by another person.
If the procedure is performed with the patient in the sitting position and
an opening pressure is required (as in the case of pseudotumor cerebri),
replace the stylet and have an assistant help the patient into the left
lateral recumbent position. There are no data suggesting that a position
change will increase the risk of spinal headache or transection of the
spinal nerves. Take care, however, not to change the orientation of the
spinal needle during this maneuver.

LUMBAR PUNCTURE

8 L3-L4 interspace palpation

10 5 Describe
mts the each Wearing non-sterile gloves, locate the L3-L4 interspace by
palpating the right and left posterior superior iliac crests and moving the
and
fingers medially toward the spine. Palpate that interspace (L3-L4), the
every
interspace above (L2-L3), and the interspace below (L4-L5) to find the
steps in
widest space. Mark the entry site with a thumbnail or a marker. To help
detail of
open the interlaminar spaces, ask the patient to practice pushing the entry
lumbar
site area out toward the practitioner.
puncture
CSF collection tubes
Open the spinal tray, change to sterile gloves, and prepare the
equipment. Open the numbered plastic tubes, and place them upright.
Assemble the stopcock on the manometer, and draw the Lidocaine into the
10-mL syringe.
 Skin preparation
Use the skin swabs and antiseptic solution to clean the skin in a
circular fashion, starting at the L3-L4 interspace and moving outward to
include at least 1 interspace above and 1 below . Just before applying the
skin swabs, warn the patient that the solution is very cold; application of an
unexpectedly cold solution can be unnerving for the patient.
Drape application
Place a sterile drape below the patient and a fenestrated drape
on the patient Most spinal trays contain fenestrated drapes with an adhesive
tape that keeps the drape in place.
Local anesthesia
Use the 10-mL syringe to administer a local anesthetic. Raise a
skin wheal using the 25-gauge needle, then switch to the longer 20-gauge
9 needle to anesthetize the deeper tissue. Insert the needle all the way to the
hub, aspirate to confirm that the needle is not in a blood vessel, and then
inject a small amount as the needle is withdrawn a few centimeters.
Continue this process above, below, and to the sides very slightly (using the
same puncture site).Local Anesthetics
Local anesthetic agents are used to increase patient comfort during the
procedure.
Regional Anesthesia (IV) Lidocaine4 mg/kg
 Lidocaine is an amide local anesthetic used in a 1-2%
concentration. This agent inhibits depolarization of type C sensory neurons
by blocking sodium channels. Epinephrine prolongs the effect and enhances
hemostasis (maximum epinephrine dose, 4.5-7 mg/kg).
 Spinal needle insertion

This process anesthetizes the entire immediate area so that if

redirection of the spinal needle is necessary, the area will still be
anesthetized. For this reason, a 10-mL syringe may be more beneficial than
the usual 3-mL syringe supplied with the standard lumbar puncture kit. The
20-gauge needle can also be used as a guide for the general direction of the
spinal needle. In other words, the best direction in which to aim the spinal
needle can be confirmed if the 20-gauge needle encounters bone in one
direction but not in another.

Next, stabilize the 20- or 22-gauge needle with the index

fingers, and advance it through the skin wheal using the thumbs (see the
video below). Orient the bevel parallel to the longitudinal Dural fibers to
10
increase the chances that the needle will separate the fibers rather than cut
them; in the lateral recumbent position, the bevel should face up, and in the
sitting position, it should face to one side or the other.

Opening pressure measurement

Insert the needle at a slightly cephalad angle, directing it

toward the umbilicus. Advance the needle slowly but smoothly.
Occasionally, a characteristic “pop” is felt when the needle penetrates the
Dura. Otherwise, the stylet should be withdrawn after approximately 4-5 cm
and observed for fluid return. If no fluid is returned, replace the stylet,
advance or withdraw the needle a few milli meters, and recheck for fluid
return. Continue this process until fluid is successfully returned.
 For measurement of the opening pressure, the patient must be
in the lateral recumbent position. After fluid is returned from the needle,
attach the manometer through the stopcock, and note the height of the fluid
column. The patient’s legs should be straightened during the measurement
of the open pressure, or a falsely elevated pressure will be obtained

Spinal needle removal

Collect at least 10 drops of cerebrospinal fluid (CSF) in each of

the 4 plastic tubes, starting with tube 1. If possible, the CSF that is in the
manometer should be used for tube 1. If the CSF flow is too slow, ask the
patient to cough or bear down (as in the Valsalva maneuver), or ask an
assistant to press intermittently on the patient’s abdomen to increase the
11 flow. Alternatively, the needle can be rotated 90° so that the bevel faces
cephalad.

Replace the stylet, and remove the needle . Clean off the skin
preparation solution. Apply a sterile dressing, and place the patient in the
2 supine position.
11 mts Provide
optimal AFTER CARE OF THE PATIENT
care to
 As soon as the needle is withdrawn , seal the puncture site to prevent
the
leakage of CSF.
patient
 Place the patient comfortably on the bed in supine position.
after the  If the patient develops post puncture headache, the following
procedur precautions are taken.
e
o Darken the room
 o Give plenty of oral fluids to re-establish the CSF level
o If the patient develops post puncture headache, the following
precautions are taken
o Darken the room
o give plenty of oral fluids to re-establish the CSF level.
o Administer analgesics.
o Raise the foot end of the bed
 The patient should be watched constantly for several hours after L.P.
Record then vital signs .
 Record the procedure on a patients chart with date and time.
 The specimens of CSF collected should be sent to the laboratory
without any delay with proper labels and a requisition form.
 If there are no complications observed, the patient may be allowed to
be upright after 8 to 12 hours.
12
Cerebrospinal Fluid Analysis

If the CSF has been collected under sterile conditions,

microbiologic studies can now be performed. Stains, cultures, and
immunoglobulin titers may be obtained; the last are of special importance
with diseases in which peripheral manifestations fade while central nervous
system (CNS) symptoms persist (e.g., syphilis and Lyme disease).
LABORATORY TEST
Different institutions have different protocols for the studies performed on
the various CSF tubes. The classic approach is to send the 4 CSF tubes for
the following studies:

 Tube 1 - Cell count and differential

  Tube 2 - Glucose and protein levels
12 3 Enlist the  Tube 3 - Gram stain, culture and sensitivity (C&S)
mts different
 Tube 4 - Cell count and differential
methods
of CSF At some institutions, only 3 tubes are sent for analysis, and tube 4 is
analysis reserved for special studies when indicated. In this approach, the following
studies are done:

 Tube 1 - Protein and glucose levels

 Tube 2 - Gram stain, C&S
 Tube 3 - Cell count and differential

When indicated, viral titers or cultures, Venereal Disease Research

Laboratory (VDRL) tests, Cryptococcus antigen assays, India ink stains,
13
angiotensin-converting enzyme (ACE) levels, or other studies are ordered.
Additional tests may be warranted, depending on the clinical situation. All
specimens should be taken to the laboratory promptly to prevent hemolysis
and specimen misplacement.
Separate specimens should be sent for microscopic study and for
centrifugation. The latter must be done promptly because red blood cells
(RBCs) hemolyze within a few hours. The lymphocyte count in normal CSF
may be as high as 5/µL.

Cytologic assessment

A larger-than-usual number of white blood cells (WBCs)

suggests an infection or, more rarely, leukemic infiltration. Although
bacterial infections are traditionally associated with a preponderance of
 polymorph nuclear leukocytes (PMNs), many cases of viral meningitis and
encephalitis also show a high percentage of PMNs in the acute phase of the
illness (when most lumbar punctures are done). In addition, inflammation
from any source (e.g., CNS vasculitis) can raise the WBC count.
A traumatic tap, of course, introduces WBCs and RBCs into
the CSF. An approximation of 1 WBC for every 1000 RBCs can be made,
though a repeat tap may be preferable. Although no normal value for RBCs
in the CSF is known, an occasional RBC may be incident to the tap itself.
Multiple lumbar puncture examinations may be required in
testing for leptomeningeal malignancies. At least 3 negative Cytologic
evaluations (ie, 3 separate samplings) are required to rule out
leptomeningeal malignancy (eg, leptomeningeal carcinomatosis).
14
Protein assessment

Assessment of CSF protein level, though nonspecific, can be a

clue to otherwise unsuspected neurologic disease. The high protein levels in
demyelinating polyneuropathies, or post infectious states, can be
informative. A traumatic tap can introduce protein into the CSF. An
approximation of 1 mg of protein for every 750 RBCs may be used, but a
repeat tap is preferable.

Glucose assessment

The CSF glucose level normally approximates 60% of the

peripheral blood glucose level at the time of the tap. A simultaneous
measurement of blood glucose (especially if the CSF glucose level is likely
 to be low) is recommended.
A low CSF glucose level is usually associated with bacterial
infection (probably due to enzymatic inhibition rather than to actual
bacterial consumption of the glucose). This finding is also seen in tumor
infiltration and may be one of the hallmarks of meningeal carcinomatosis,
even with negative cytologic findings. A high CSF glucose level has no
specific diagnostic significance and is most often spillover from an elevated
blood glucose level.

Xanthochromia

The best way of distinguishing RBCs related to intracranial

bleeding is to examine the centrifuged supernatant CSF for xanthochromia
15 (yellow color). Although xanthochromia can be confirmed visually, it is
more accurately identified and quantified in the laboratory.
Although xanthochromia can be produced by spillover from a
very high serum bilirubin level (> 15 mg/dL), patients with severe
hyperbilirubinemia (eg, from jaundice or known liver disease). usually have
been identified before lumbar puncture. With this exception, xanthochromia
in a freshly spun specimen is evidence of preexistent blood in the
subarachnoid space. However, it should be remembered that an extremely
high CSF protein level, as seen in lumbar punctures below a complete spinal
block, also renders the fluid xanthochromic, though without RBCs.
Xanthochromia can persist for as long as several weeks after a
subarachnoid hemorrhage (SAH). Thus, it has greater diagnostic sensitivity
than computed tomography (CT) of the head without contrast, especially if
 the SAH occurred more than 3-4 days before presentation. Patients with
aneurysmal leaks (eg, sentinel hemorrhages) may present days after the
onset of headache, and this increases the likelihood of a false-negative head
CT scan.
In some cases, the CSF may be another color that strongly
suggests a diagnosis. For example, pseudomonal meningitis may be
associated with bright-green CSF.

The Evaluation Normal Findings What abnormal

CSF findings may
indicate
Pressure Adults: Less than 200mm tumors,
H2O Children: Less than 100 hydrocephalus,
16 mm H20 intracranial bleeding

13 2 Distingui Color Clear and colorless Cloudy-bacteria,

mts sh the WBCs Red-tinged-
normal subarachnoid
and bleeding
abnormal Blood None Cerebral hemorrhage
findings or Traumatic tap
of CSF (inadvertent
analysis rupturing a blood
result. vessel )
Cells No Red blood cells, <5 Red blood cells--an
lymphocytes/mm2 indication of the
amount of blood
 within the spinal
canal, White blood
cells--cerebral
abscess, bacterial
meningitis, viral
meningitis,
tubercular
meningitis,
encephalitis
Culture & No organisms present Bacterial or fungal
Sensitivity infection
Protein 15 -45 mg/dl up to 70mg/dl Meningitis,
17
for elderly and children encephalitis,
myelitis, tumors,
inflammatory
processes
Glucose 50 - 75 mg/dl or 60 to 70% Meningitis,
of blood glucose level neoplasm
Chloride (not 700 - 750 mg/dl Meningeal
routinely infections,
evaluated) tubercular
meningitis
Lactic <2.0 - 7.2 U/ml Bacterial meningitis,
dehydrogenase inflammation
Lactic acid 10 - 25 mg/dl Bacterial or fungal
 meningitis
Cytology No malignant cells Tumors of brain and
spinal cord
Glutamine 6 -15 mg/dl Hepatic
encephalopathy,
Reye's syndrome

COMPLICATIONS
Possible lumbar puncture–related complications include the following:

 Uncal or tonsillar herniation

18  Reversible tonsillar descent
 Spinal coning in patients with rostral subarachnoid block
 Postdural puncture headache
 Cranial neuropathies
 Nerve root irritation, herniation, and transection
 Low back pain
 Implantation of epidermal tumors
 Infections
14 3m Anticipate
 Bleeding complications
ts the
 Intracranial bleeding
possible  Traumatic lumbar puncture
complica  Spinal hematomas
tions  Other complications
and its o Vasovagal syncope
causes, o Cardiac arrest
 signs and o Seizures
symptoms o Subarachnoid cyst
related to o Low pressure state in children with ventriculoperitoneal (V-P)
lumbar shunt
puncture o Pseudo-pseudotumor cerebri (incorrect measurement of
opening pressure)
o Incorrect lab analysis of cerebrospinal fluid

Post–spinal puncture headache

Headache is the most common complication of lumbar

puncture, observed in 20-70% of patients. It usually begins 24-48 hours
after the procedure and is more common in young adults. The probable
etiology is continued leakage of CSF from the puncture site. The headache
19 is usually fronto-occipital and improves in the supine position.
This condition is usually self-limited (≤7 days) and responds to
analgesics and caffeine (300-500 mg every 4-6 hours). Severe cases can be
treated with an epidural blood patch performed by an anesthesiologist or a
pain specialist. Pencil-tip (Whitacre) needles are associated with a
significantly lower incidence of post–spinal puncture headaches than are
standard bevel-tip (Quincke) needles.

Bloody tap

More than 50% of lumbar punctures are falsely positive for

RBCs in the CSF as a result of micro trauma caused by the spinal needle.
This is an uncomplicated occurrence in healthy patients with a normal
coagulation system.
 Dry tap

Dry taps usually result from misplacement of the spinal needle. The most
common mistake is a lateral displacement, which can easily be corrected by
withdrawing the needle completely, reevaluating the patient’s anatomy, and
reinserting the needle in the correct place and at the proper angle. In obese
patients, the regular spinal needle might be too short, in which case a longer
one should be used.

If the patient is dehydrated, a falsely negative dry tap may be

obtained as a result of very low CSF volume and pressure. If this is
suspected, attempt to rehydrate the patient before the procedure.
Infection
20
Cellulitis, skin abscesses, epidural abscesses, spinal abscesses,
or diskitis can result from a contaminated spinal needle. Adherence to sterile
technique, including gloves, gowns, hair covers, and face masks, as well as
thorough skin cleansing and disinfecting, should minimize this risk.

Hemorrhage

Epidural, subdural, and subarachnoid hemorrhage are rare

complications that might carry significant morbidity and mortality in
coagulopathic patients. Lumbar puncture should be deferred in patients with
low platelets counts (< 50,000/µL) or patients with other coagulopathies
(eg, hemophilia or supratherapeutic international normalized ratio [INR])
until the abnormality is corrected.
 Dysesthesia
Irritation of nerves or nerve roots by the spinal needle can
cause different lower-extremity dysesthesias. Withdrawing the needle
without replacing the stylet can cause aspiration of a nerve or arachnoid
tissue into the epidural space. To prevent this complication, always replace
the stylet before moving the needle.

Post–Dural puncture cerebral herniation

Cerebral herniation is the most serious complication of a

lumbar puncture. It is very rare, and there is considerable debate in the
literature regarding whether it is caused by the lumbar puncture or by the
underlying disease process. There is increasing evidence that a diagnostic
21 lumbar puncture is safe even in patients with increased intracranial pressure
(ICP), such as most patients with meningitis, but there is no firm consensus
regarding the safety of lumbar puncture in patients with ICP.
Until further data are available, a reasonable approach would
be to avoid lumbar puncture when the disease process has progressed to the
point where neurologic findings associated with impending cerebral
herniation (deteriorating level of consciousness and brainstem signs
including pupillary changes, posturing, irregular respirations, and very
recent seizure) are seen.

COMPLICATION PREVENTION

The following measures should be taken to help minimize complications of

lumbar puncture:
  Explain the procedure, benefits, risks, complications, and alternative
options to the patient or the patient’s representative, and obtain a
signed informed consent
 Before performing the lumbar puncture, ensure that patients are
hydrated so as to avoid a dry tap
 Never allow a lumbar puncture or a pre–lumbar puncture CT scan to
delay administration of intravenous (IV) antibiotics; meningitis can
15 2 Preclude usually be inferred from the cell count, antigen detection, or both
mts the ways  Avoid lumbar puncture in patients in whom the disease process has
to
progressed to the neurologic findings associated with impending
prevent
complica cerebral herniation (ie, deteriorating level of consciousness and
tions of brainstem signs that include pupillary changes, posturing, irregular
22 lumbar respirations, and very recent seizure)
puncture
The smaller the needle used for the lumbar puncture, the lower the risk that
the patient will experience a post–lumbar puncture headache. Data suggest
an inverse linear relation between needle gauge and headache incidence,
and some authors recommend using a 22-gauge needle regardless of what
size needle is supplied with the kit.
The use of atraumatic needles has been shown to significantly
reduce the incidence of post–lumbar puncture headache (3%) when
compared to the use of standard spinal needles (approximately 30%). In
addition, it may lead to cost savings. However, obtaining pressures can be
more difficult with atraumatic needles.
Prophylactic bed rest after lumbar puncture has not been shown to be of
 benefit and should not be recommended.

23
SUMMARY

So for we have know about lumbar puncture procedures under different headings like definition, purposes, indications,
contraindications, technical or equipments, Preparation of patient by position, Steps involved in LP and complications prevention
including nursing care before, during and after the procedure.

CONCLUSION

The lumbar puncture in expert hands is a safe test. The health professional should be suitably familiar with its contraindications, the
24
regional anatomy and the technique used to perform it. It is essential and emergency procedure in order to diagnose or eliminate the
disease process by the careful aspiration and analysis of CSF. So the e care must be taken by the nurses to avoid complications ,
repetitions of LP due to improper handling of specimen like incorrect labeling, spills CSF which makes the doctor and patient gets
frustrated with such of carelessness.
BIBLIOGRAPHY


  Annamma Jacob, Clinical Nursing Procedures, Second Edition, Jaypee Publication (2010
 Mansukh.B.Patel - Ward Procedures Fourth Edition, Elsevier Publication PP: 285 - 301
 Shakunthala Sharma, Principles And Practice Of Nursing, Second Edition, Jaypee Publication,
 Frank.M.Pierson, Principles And Techniques Of Patient Care, Third Edition, Saunders Publication
 Sr. Nancy, “Principles An Practice Of Nursing” Senior Nursing Procedure, Fourth Edition, (2006), N.R. Publishing House,
Indore
 K.Sembulingam "Essentials of Medical physiology" 3rd edition, 2004 Jaypee publishers.Patricia A. Potter " Fundamentals
of nursing" 2005, Mosby publishers.
 .Suzanne C.Smeltzer " Textbook of Medical _ Surgical Nursing" 10th Edition, 2004, Lippincott Williams and Wilkins
publishers
25


NET REFERENCE:
 www.ncbi.nlm.nih.gov/pubmed/17918111
 www.msn.com
 www.google.com
 www.wikipedia.com
 www.scrib.com