INDORE COLLEGE OF NURSING

A
CASE STUDY OF
GUILLAIN-BARRE
SYNDROME GBS

SUBMITTED BY, SUBMITTED TO,

JERIN THOMAS MRS TAMIL SELVI
1ST YEAR MSC NURSING INDORE COLLEGE OF NURSING
INDORE COLLEGE OF NURSING

SUBMITTED ON

1
 CASE STUDY

 PATIENT INFORMATION :
 Patient’s Name : Mr. Sunil Yalwande
 Age : 16 years Sex : Male
 Address :
 Admission Date : 20/11/14
 Ward : ICU
 Indoor NO : 639969
 Education : 10th standard
 Occupation : farmer
 Religion : Hindu
 Blood group : O +ve

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  Discharge Date : ------
 Diagnosis : Guillain-Barre Syndrome GBS
 Income per month : 9000 Rs./ month(family)
 Weight : 35 kg Height : 152 cm
 Health Habits :
- Smoking : No
- Tobacco chewing : No
- Alcohol Consumption : No
 Vegetarian : Yes
 Non-vegetarian : 2-3 Times/week
 Chief complaints with duration : Complaint of throat pain since 5 days
Complaint of fever since 5 days
Complaint of Difficulty in Swallowing since 5 days
Complaint of Regurgitation since 2 days,
Complaint of Loss of Motor power since 2days.

 HISTORY OF THE PATIENT :

1) Family history :

Age Relationsh
Illness in
Sr. Name of Family in ip Occupation
Family Education
No. Members Yea With
Members
r Patient
1 Pravinji Yalwande 53 Father TB Illiterate Farmer
2 Sunita Yalwande 50 Mother No 9th std. Housewife
3 Gopal Yalwande 22 Brother No 12th std. Shop keeper
4 Radha Yalwande 20 Sister in No 10h std. Housewife
law
5 Sonal Yalwande 18 Sister No 8th std Student
6 Sunil Yalwande 16 Self Recently 10th std. Student
GBS

2) Past illness history :

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 Sunil was very healthy.He didn’t had any illness and didn’t took any regular
medicine. He had no other major illness like TB, HT, DM or any congenital
abnormalities etc.

3) Present health history :

Sunil had complaint of throat pain ,fever, Difficulty in swallowing since 5 days.
So he came on date 20-11-11 and he was seen by Dr N.M.Kadri. At that time, he was
diagnosed as a tonsillitis and admitted in ward general ward. Treatment was started
but gradually patient lost his motor power of four limb and also Paletal muscles
were involved on date19-11-11. Also nasal regurgitation occurred on date 22-10-11.
Respiratory muscles were involved and there was a need to put patient on ventilator
and he was shifted to ICU. Then he was finally diagnosed as Guillain-Barre
Syndrome GBS.

4) Personal history :

Sunil looks well nourished, his skin colour is brown. He has no bad habit. He
eats non-vegetarian food .In the routine food he takes dal, roti, rice and sabji 2
times in a day. He would like to take tea, he takes tea 5-6 times in a day. Some
times in the food he likes veg. biriyani, sher Khurma, samosa, idali sambhar etc. he
does not like any soup and salad.

i) Personal hygiene :
- Oral hygiene : once a time with tooth brush.
- Bath : once in a day daily
- Sleep and Rest : 7 hours/ day and 1 hour rest in afternoon time daily
ii) Elimination :
- Bowel per day : Regular per day, once in morning time daily.
- Urine frequency : 1500 ml/ day
iii) Mobility and Exercise :
- Moderate : Moderate exercise he has doing.
- Joint pain during walking. Restricted movement of the leg.
iv) Sexual and Marital history :
He is not married.

5) Health facility near Home :

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 There are some clinics near his home where primary care can be provided.
Transport facility is available in the form of Government bus services as well as
private vehicles are also available for transportation.

6) Housing :

Sunil has his own pakka house in Vishrantwadi. The house is having 2 rooms, 1
kitchen and facilities of toilet and bathroom are also available in house. There is also
facilitiy of electricity and drinking water from the borewell.

 NURSING ASSESSMENT :

a) General observation :
 Sensorium : he is conscious and well oriented
 Foul body odour : no any bad odour from his body
 Foul breath : no
 Posture : normal
 Hair : black and shiny hair, Clean no any dandruff.

b) Vital sign :
 Temperature : 98.4 F.
 Pulse : 88 /min.  Regular  high volume  Tachycardia (some time)
 Respiration : 26 /min.  Tachypnea
 BP : 120/80 mm of Hg.

c) Subjective data :
Patient is on ventilator so he can not speak but by sign language indicates
Restlessness, fatigue, psychologically disturbance

d) Objective Data :

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 Assessment of Cardiovascular system :
 Heart rate : 88 beats/min.
 Rhythm : Regular
 Apical Pulse : 88 beats/min.
 Jugular vein distention : No.
 Spo2: 94%.

Respiratory System :
 Respiration rate : 26 breaths /minwith help of ventilator
 Breath sound : normal
 Dysponea : Present.
 Pulmonary effusion : No.
 Cough: Productive cough.

Abdomen :
 Hepatomegaly : No.

Skin :
 Color of mucous membrane : Pink
 Peripheral Cyanosis : No. Clubbing: No.
 Ecchymosis : No

Urinary system :
 Urine output : 1700 ml/24hrs.

Extremities :
 Edema : No
 Color and Temperature of Skin : Cold and clammy.

 DIAGNOSTIC TESTS :

i) Biochemical Test:

Sr. Biochemical test Patient’s Report Normal Value

no.
1. CBC
- Hb 12.59 gm % M- 13.5-18 gm%
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 F – 12- 14 gm %
- Total count 18,600 / cumm 4500-11000/cu mm
- Differential count
 Polymorphs 80 % 66 – 70 %
 Lymphocytes 18 % 20 – 45 %
 Eeosinophil 01 % 1–4%
 Monocytes 01 % 2–4%
 Basophil 00 % 0–1%
- Platelet counts 2,22,000/ cumm 150000 – 450000

2. Sr. Electrolytes
- Bl. Urea 33.0 mg / dl 13- 40 mg / dl
- Sr. Creatinine 0.7 mg / dl 0.8- 1.4 mg / dl
- Sr. Na+ 136m Eq/ L 135 – 149 m Eq/ L
- Sr. K+ 3.5m Eq/ L 3.5 – 5.5 m Eq/ L
- Sr. Cl- 104 m Eq/ L 98 – 108 m Eq/ L
- Sr. Bil. Total : 0.8 mg % 0.0 – 1.0 mg %
Direct : - 0.0 – 0.25 mg %
Indirect : - 0.0 – 0.75 mg %
- S. G. P. T 14.0 IU/L 0 – 40 U/L
- Sr. Alkaline Phosphate 200.5 U/L 124 – 341 U/L
- Total Proteins : 6.36 G/L 6.6 – 8.3 G/L
Albumin : 4.42 G/L 3.5 – 5.0 G/L
Globulin : 1.94 G/L 2.3 – 3.3 G/L
A/G ratio : 2.22 1.0 – 4.0

- Bl. Sugar 110 mg/dl. 65-140mg/dl.

3. Prothombine time
- Patient 12.8 Second
- Control 12 second
- INR 1.074 second

4. HIV Negative Negative

5. HBsAg Negative Negative

ii) Special Tests :

Sr. Biochemical Patient’s Report Normal Value

no. test
1. X-ray chest Normal - Lungs clear.
- No cavity
- BVM Normal
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 2. ECG - Rate : 60-100/min
Normal rhythm. - P : Height<2.5mm
Rate : 88 /min. - Width< 2.5mm
- ORS: < 0.10 Sec.
- Depth & width of
Q wave - <0.04mm
3. Echocardiogra o Tricuspid valve and pulmonary
phy valve is normal
o LVEF – 60%
o Aorta – 34 mm, LA – 48 mm
o RA and RV – normal
o Aortic signal – O2 Max. – 62 mm
Hg
O2mean – 34 mm Hg
O2mini – 39 m/s
o LVOT diameter – 21 mm
o AR jet width – 8.8 mm
o Conclusion : Cardiac size and
activity is normal.no any abnormality
related to heart.
o Done by : Dr.Samir Dani
4. MRI Brain Normal MR study of brain.Nodefinit focal
lision.normal appearance of posterior fossa
structures.
5. ABG - PCO2-61.4mmhg
- PO2-32.7mmhg
- HCT-43%
- K-3.05mm0l/l

 FINAL DIAGNOSIS :- Guillain-Barre Syndrome (GBS)

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 INTRODUCTION OF GBS
Anatomy & Physiology

The nervous system consists of two divisions: the central nervous system (CNS),
including the brain and spinal cord, and the peripheral nervous system, made up of
the cranial and spinal nerves. The peripheral nervous system can be further divided
into the somatic, or voluntary, nervous system, and the autonomic, or involuntary,
nervous system. The function of the nervous system is to control all motor, sensory,
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autonomic, cognitive, and behavioral activities. The nervous system has
approximately 10 million sensory neurons that send information about the internal
and external environment to the brain and 500,000 motor neurons that control the
muscles and glands. The brain itself contains more than 20 billion nerve cells that
link the motor and sensory pathways, monitor the body’s processes, respond to the
internal and external environment, maintain homeostasis, and direct all
psychological, biologic, and physical activity through complex chemical and electrical
messages.The brain is divided into three major areas: the cerebrum, the brain stem,
and the cerebellum. The cerebrum is composed of two hemispheres, the thalamus,
the hypothalamus, and the basal ganglia. Additionally, connections for the olfactory
(cranial nerve I) and optic (cranial nerve III) nerves are found in the cerebrum. The
brain stem includes the midbrain, pons, medulla, and connections for cranial nerves
II and IV through XII. The cerebellum is located under the cerebrum and behind the
brain stem. The brain accounts for approximately 2% of the total body weight; it
weighs approximately 1,400 g in an average young adult.

GUILLAIN-BARRE SYNDROME (POLYRADICULONEURITIS)

DEFINITION
Guillain-Barre syndrome (GBS) is an acute, rapidly progressing, ascending
inflammatory demyelinating polyneuropathy of the peripheral sensory and motor
nerves and nerve roots. GBS is most often, but not always, characterized by
muscular weakness and distal sensory loss or dysesthesias. GBS is the most
frequently acquired demyelinating neuropathy. It affects one in 100,000 people and
must be identified quickly to initiate treatment and decrease life-threatening
complications. Usually GBS occurs a few days or weeks following symptoms of a
respiratory or GI viral infection. Occasionally, surgery or vaccinations will trigger the
syndrome. The disorder can develop over the course of hours, days, or weeks.
Maximum weakness usually occurs within the first 2 weeks after symptoms appear,
and by the third week of the illness 90% of all patients are at their weakest. About
30% of those with GBS have residual weakness after 3 years and the recurrence rate
is approximately 3%.
Mortality results form respiratory failure, autonomic disturbances, sepsis, and
complications of immobility and occurs at a rate of about 5% despite intensive
medical care.

“Guillain-Barre syndrome is a clinical syndrome of unknown cause involving the

peripheral and cranial nerves”.

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  In most patients, the syndrome is preceded by an infection (respiratory or
gastrointestinal) 1 to 4 weeks before the onset of neurologic deficits.
 In some instances, it has occurred after vaccination or surgery It may be due
to a primary viral infection, an immune reaction, some other process, or a
combination of processes.
 One hypothesis is that a viral infection induces an autoimmune reaction that
attacks the myelin of the peripheral nerves.
 Proximal portions of the nerves tend to be affected most often, and the nerve
roots within the subarachnoid space are commonly involved. Autopsy findings
have shown inflammatory edema and demyelination with some lympho-cytic
infiltration that is especially prominent in the spinal nerve roots.

CLINICAL MANIFESTATIONS

SRNO IN BOOK IN PATIENT

1 Respiratory Infection Not present
2 G.I infection Present
3 Tingling and numbness Present
4 muscle weakness of the legs Present
5 Gradually respiratory muscles involved Present
6 difficulty in talking, chewing, and Difficulty in swallowing
swallowing
7 disturbances of heart rate and rhythm, Present some time
blood pressure changes
8 persistent pain in the back and calves of Not Present
the legs
9 loss of position sense Not Present
10 paresthesias. Not Present

MANAGEMENT :

SPECIAL MANAGEMENT
Plasmapheresis

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 Done in patient on date 23-11-11

 MEDICAL MANAGEMENT TREATMENT :-

First Sunil was put on medical treatment. He was on following medicines:

- Inj.DNS 1pint 8 hourly
- Inj.MVI 1 amp /day
- Inj. Fortum 1 Gm IV 12 hourly
- Inj. Amikacin 500 mg IV 12 hourly
- Tab. Warf (5 mg ) 1 OD
- Tab. Alprax 0.25 mg 1 HS
- Tab.BC/FA 1Bd
- Liq. Cremaffin 3TSF HS
- Input chart
- Urine Output chart
- O2 Inhalation SOS.
- Asthalin Nebulization 8 hourly

 NURSING MANAGEMENT :

 Ineffective breathing pattern and gas exchange related to rapidly progressive

weakness and impending respiratory failure as evidenced by vital signs.
 Impaired physical mobility related to paralysis as evidenced by motor
weakness.
 Imbalanced nutrition related to inability to swallow as evidenced by low level
of electrolytes.
 Risk for infection related to hospitalization as evidenced by increase in WBC
count.
 Activity intolerance due to motor weakness.
 Anxiety related to hospitalization as evidenced by facial expression.
 Deficit knowledge about self care.

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13
 NURSING CARE PLAN

Patient Name : Sunil Yalwande Age : 16Yrs Wt : 35kg Diagnosis : GBS Date : 21-11-11

Nursing Nursing Diagnosis Expected Implementation Evaluation

Assessment Outcome
Respiration rate is Ineffective To relieve  Fowlers position is given to the As patient is on
26/minute. breathing pattern dyspnea patient ventilator, the rate is
Patient is having and gas exchange  Patient kept on ventilator. maintained. Also the
Dyspnoea related to rapidly  Every 2 hourly suction done. SpO2 level of the patient
progressive  Maintained urine out put chart is maintained.
weakness and  Every 2 hourly asthalin
impending nebulization
respiratory failure Given.
as evidenced by  ABG done.
vital signs.
Patient is not able Impaired physical To improve  Physiotherapy at list 2 times Day by day motor power
to move his limbs. mobility related to in Motor /day by physiotherapist and 2 is improving.
paralysis as power. hourly rom exercise given.
evidence by motor  Change the position every 2
weakness hourly to prevent complications.
 Maintain electrolytes by
giving I.V fluids for maintaining
skin integrity.
Body weight Imbalanced To maintain  Ryle’s tube feeding every 2  Electrolyte
according to the nutrition related to electrolytes. hourly 50 ml given. level of the patient is
height is less. inability to swallow  Also all i.vfluids as per Dr’s order maintained.
Anorexia. as evidenced by given for maintaining
Low electrolyte low electrolyte electrolytes.
level. level  Patient having trecheostomy so
he can take food by orally so
gradually motivate the patient
for that.

NURSING CARE PLAN

Nursing Nursing Expected Implementation Evaluation

Assessment Diagnosis Outcome
Patient is Risk for Patient  Maintain nutrition level of the No any significant
hospitalized for infection remains free patient. infection seen.
a long time. related to from  All antibiotics given regularly to
WBC count has hospitalization infection. the patient as per Dr’s order.
increased. as evidenced by  Daily trecheostomy dressing
increase in WBC done by aseptic technique.
count.  All other routine procedure done
by aseptic technique
 Every 2 hourly position changed
to prevent bedsore.
 Stroking apply to prevent DVT.
Fatigue Activity To relieve the  Assessed for daily living activity. Assisted in daily living
Weakness intolerance due fatigue  Instructed the patient to do all activities.
Inability to do to motor activities in the bed.
ADL weakness  Provided bed side commode.
Paralysis  Assisting with daily living
present activities

NURSING CARE PLAN

Nursing Nursing Diagnosis Expected Nursing Intervention Evaluation

Assessment Outcome
Patient is Anxious Anxiety related to Reduction of  Encouraged the client to ask  Anxiety was reduced
Fear about disease hospitalization anxiety questions and allow cline tot upto certain level by
and hospitalization verbalize fears. provision of diversion
 Provide comfortable, quiet therapy
environment and necessary
information.
 Diversion therapy was used by
providing magazine and
newspaper.
Patient and his Knowledge deficit Ability to  Give teaching regarding diet,
family members about self care perform self activity, exercise, vital signs  Family can help the
asked about his care activities monitoring, ROM patient and also they
disease and the exercise,medication regimen, can able to detect the
prognosis CPR if appropriate family any cardiac
member learn. emergencies.
 Provide several teaching
sessions for reinforcement and
answering questions.
 After cardiac surgery patient
have short term memory,
written information is helpful so
all the medication is written in
the patient’s language with its
dose, time and other
instruction.
 Management for phone
contacts with health care
personnel help to alley anxiety.
 DRUG SHEET

Patient Name : Popatji P Thakor Age : 13 Years Wt : 35 kg Diagnosis : GBS Date : 20-11-11.

Sr. Side effects

Drugs Rout Mechanism of
No Dose Indications Nursing Consideration
Name e Action
.
1 Inj DNS 1500/da I.V Fluids Maintain - -
y Nutrition level

2. Inj MVI 1amp I.V Multivitamines Supliment - -

Vitamines

3. Inj Rl 1000/da I.V Fluids Maintain - -

y Nutrition level

4. Inj. 1 Gm I.V Antibiotics - Serious - Skin rash, urticaria, - Give slowly

Fortum infection of the neutropenia, - See the injection
respiratory thrombocytopenia, pain site for phlebitis.
tract, ENT, skin, at injection site, fever,
G.I.etc. headache, phlebitis.
5. Inj. 500 mg IV Antibiotics - Bacteraemias, - Hypersensitivity - Give slowly
septicemias, reactions, nausea, - Assessed for
Amikacin
burns and post vomiting,nephrotoxicity, accurate doses.
operative ototoxicity - Monitor urine
infections output.

Sr. Side effects

Drugs Rout Mechanism of
No Dose Indications Nursing Consideration
Name e Action
.
- Pulmonary - Bleeding, alopecia, - Watch for bleeding
embolism, - bleeding from gums, from any site,
- venous - thrombocytopenia, - Do not leave the
16 Tab. Warf Oral thrombosis, patient alone
5 mg Anitcoagulant
oral - atrial - If acute bleeding from
fibrillation any site then
- with immediately inform
embolism to doctor.
7 Tab. 0.25 mg Oral Sedative - Short-term - Anorexia, nausea, - Do not leave the
symptomatic - drowsiness, pruritis, patient alone.
Alprax
- treatment of - loss of memory, - Give proper amount
anxiety, - loss of co-ordination, of dose.
- panic - slurred speech - Do not give during
 disorders, day timings unless it
- depression is advised by doctor.

- Constipation, - Prolonged use or

bowel overdose can - It should only give in
clearance precipitate the onset the night only.
Liq. Oral before of an atonic non- - Give correct amount
8. 4 - 6 tsf Laxative
Cremaffin radiography, functioning colon of dose because
endoscopy, and hypokalamia. overdose creates the
labour and diarrhea.
surgery.
 HEALTH EDUCATION

 Advise patient and family that acute phase lasts 1 to 4 weeks, then patient
stabilizes and rehabilitation can begin; however, convalescence may be
lengthy, from 3 months to 2 years.
 Instruct patient in breathing exercises or use of incentive spirometer to
reestablish normal patterns.
 Teach patient to wear good supportive and protective shoes while out of bed
to prevent injuries due to weakness and paresthesia.
 Instruct patient to check feet routinely for injuries because trauma may go
unnoticed due to sensory changes.
 Reinforce maintenance of normal weight; additional weight will further stress
the motor abilities.
 Encourage the use of scheduled rest periods to avoid over-fatigue.
 Be aware that GBS is a significant cause of new long-term disability for at least
1,000 persons per year in the United States, necessitating long-term
rehabilitation and community reintegration. Outcome can range from mild
paresthesias to death. The chance of recovery is significantly affected by age,
antecedent gastroenteritis, disability, electrophysiologic signs of axonal
degeneration, latency to nadir, and duration of active disease.
 Given the young age at which GBS sometimes occurs, the patient and family
care must be treated as an integral unit, assessing family communication,
knowledge, adjustment, and use of support systems.
 Include in caregiver training strategies the need for exercise, positioning, and
activity to prevent secondary complications, such as contractures, deep vein
thrombosis (DVT), hypercalcemia, and pressure ulcers.
RESEARCH

Abstract

Guillain Barré syndrome is one of the best examples of a post infectious immune
disease and offers insights into the mechanism of tissue damage in other more
common autoimmune diseases. Controlled epidemiological studies have linked it to
infection withCampylobacter jejuni in addition to other viruses including
cytomegalovirus and Epstein Barr virus. The syndrome includes several pathological
subtypes, of which the most common is a multifocal demyelinating disorder of the
peripheral nerves in close association with macrophages. Evidence from histological
examination of peripheral nerve biopsy and postmortem samples suggests that both
cell mediated and humoral mechanisms are involved in the pathogenesis.
Immunological studies suggest that at least one third of patients have antibodies
against nerve gangliosides, which in some cases also react with constituents of the
liposaccharide of C jejuni. In the Miller Fisher variant of the disease, these
antiganglioside antibodies have been shown to produce neuromuscular block, and
may in part explain the clinical signs of that disorder. Treatment with both
intravenous immunoglobulin and plasma exchange reduces the time taken for
recovery to occur, although mortality remains around 8%, with about 20% of
patients remaining disabled.

Department of Neurology, Queen Elizabeth Hospital, Edgbaston, Birmingham B15

2TH, UKDr Winer j.b.

Abstract
Guillain-Barré syndrome consists of at least four subtypes of acute peripheral
neuropathy. Major advances have been made in understanding the mechanisms of
some of the subtypes. The histological appearance of the acute inflammatory
demyelinating polyradiculoneuropathy (AIDP) subtype resembles experimental
autoimmune neuritis, which is predominantly caused by T cells directed against
peptides from the myelin proteins P0, P2, and PMP22. The role of T-cell-mediated
immunity in AIDP remains unclear and there is evidence for the involvement of
antibodies and complement. Strong evidence now exists that axonal subtypes of
Guillain-Barré syndrome, acute motor axonal neuropathy (AMAN), and acute motor
and sensory axonal neuropathy (AMSAN), are caused by antibodies to gangliosides
on the axolemma that target macrophages to invade the axon at the node of
Ranvier. About a quarter of patients with Guillain-Barré syndrome have had a
recent Campylobacter jejuni infection, and axonal forms of the disease are especially
common in these people. The lipo-oligosaccharide from the C jejuni bacterial wall
contains ganglioside-like structures and its injection into rabbits induces a
neuropathy that resembles acute motor axonal neuropathy. Antibodies to GM1,
GM1b, GD1a, and GalNac-GD1a are in particular implicated in acute motor axonal
neuropathy and, with the exception of GalNacGD1a, in acute motor and sensory
axonal neuropathy. The Fisher's syndrome subtype is especially associated with
antibodies to GQ1b, and similar cross-reactivity with ganglioside structures in the
wall of C jejuni has been discovered. Anti-GQ1b antibodies have been shown to
damage the motor nerve terminal in vitro by a complement-mediated mechanism.
Results of international randomised trials have shown equivalent efficacy of both
plasma exchange and intravenous immunoglobulin, but not corticosteroids, in
hastening recovery from Guillain-Barré syndrome. Further research is needed to
discover treatments to prevent 20% of patients from being left with persistent and
significant disability.

The Lancet, Volume 366, Issue 9497, Pages 1653 - 1666, 5 November 2005
doi:10.1016/S0140-6736(05)67665-9
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WEBSITES:
 http://mp.bmjjournals.com/content/54/6/381.abstract

 http://www.thelancet.com/journals/lancet/article/PIIS0140-

6736(05)67665-9/fulltext
 http://www.thelancet.com/journals/lancet/article/PIIS0140-

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 http://www.thelancet.com/journals/lancet/article/PIIS0140-

6736(97)12308-X/fulltext