INTRODUCTION

Skin is the largest organ system of the body the skin is indispensable for human life. Skin
forms a barrier between the internal organs and the external environment and participates in
various vital body functions. The skin is contiguous with mucous membrane at the external
openings of the digestive, respiratory and urogenital systems. Because skin disorders are
badly visible, dermatologic complaints are commonly the primary reason that patients seek
health care.

THE INTEGUMENT ORGAN: the integument as an organ and is an alternative name for
skin. The skin integumentary system includes the skin and the skin derivatives hair, nails and
glands. The integument is the body’s largest organ and accounts 15 % of body weights

The derivatives of the integumentary are:

 Hair: functions include protein and sensing light touch. Hair is composed of column
of dead keratinized cells is bound together by extracellular proteins. Hair has two
main sections the shaft superficial portion that extends out of the skin and the root-
portion that penetrates into dermis.
 Nails: participate in the grasp and handling of small things. nails are plates of tightly
packed, hard,keratinized epidermal cells it consists of nail root, nail body free edge.
 Glands: participate in regulating body temperature. There are three main types of
glands
 Sebaceous sudoriferous ceruminous.
ANATOMY OF THE SKIN, HAIR, NAILS, AND GLANDS OF THE SKIN

The skin is the largest organ of the body it is essential for human life. It forms as a barrier
between the internal organs and external environment and participates in many vital body
functions. The skin is contiguous with the mucous membrane at the eternal openings of the
digestive, respiratory, and urogenital systems. It composed of three layers: epidermis, dermis
and subcutaneous tissue. The epidermis is an outermost layer of stratified epithelial cells and
composed predominantly of keratinocytes. It ranges in thickness from about 0.1 mm on the
eyelids to about 1mm on the palms of the hands and soles of the feet. Four distinct layers
compose the epidermis. From inner most to outer most they are the stratum germinativum,
stratum granulosum, stratum lucidum, and stratum corneum. Each layer becomes more
differentiated mature and with more specific functions.

LAYERS OF SKINS:

SKINS

Epidermis: the epidermis which is contiguous with the mucous membrane and the lining of
the ear canals, consists of live, continuously dividing cells covered on the surface by thedead
cells. This external layer is almost complete replaced every 3 to 4 weeks. The dead cells
contain large amounts of keratin an insoluble fibrous protein that forms the outer barrier of
the skin and the capacity to repel pathogens and prevent excessive fluid loss from the body

Melanocytes are the specials cells of the epidermis that are primarily involved in
producing the pigment melanin, which colours the skin and hair. Productions of melanin is
controlled by a hormone secreted from the hypothalamus of the brain called melanocytes
stimulating hormone. It is believed that melanin can absorbed ultraviolet light in sunlight

Dermis: the dermis makes up the largest portion of the skin providing strength and structure.
It composed of two layers papillary and reticular. The papillary dermis it lies directly beneath
the epidermis and is composed primarily of fibroblast cells capable of producing one form of
collagen. The dermis is also made up of blood and lymph vessels, nerves, sweat and
sebaceous glands, and hair roots. the dermis is often referred to as true skin.

Hair: an outgrowth of the skin, hair is present over the entire body excepts for the palm and
soles. The hair consist roots formed in the dermis and a shaft projects beyond the skins. It
grows in cavity called a hair follicles hair follicle undergo cycles of growth. in certain
locations on the body, hair growth is controlled by sex hormones e.g.hair on face
moustached, chest hair in different parts of the body serves different functions.

Nails: on the dorsal surface of the fingers and toes, a hard, transparent plate of keratin, called
the nail, over lies the skins. The nails protect the fingers and toes by preserving their highly
sensory functions, it is a continuous throughout life, with an average grows of 0.1 mm daily.
Complete renewal of a finger nails takes about 170days, whereas toenail renewal takes 12 to
18 months
Glands of the skins: there are two types of skin gland: sebaceous and sweat glands. The
sebaceous glands are associated with hair follicles whereas sweat glands are found in the
skins over most of the body surface, but they are most heavily concentrated in the palms of
the hands and soles of the feet’s. Sweats glands are subclassified in to two categories eccrine
and apocrine the apocrine sweats glands are larger than eccrine located in the axillae, anal
region, scrotum, and labia majora.
DIFFINITIONS

Skin is the outer covering of the body in humans it is the largest organ of the integumentary
system it has different layers of ectodermal tissue and guard the underlying muscles, bones,
ligaments and internal organs.

FUNCTIONS OF THE SKIN

Thermoregulation-Evaporation of sweat and regulation ofblood flow to the dermis.

Cutaneous sensation- sensations like touch, pressure vibration, pain, warmth or coolness.

Vitamin D production- UV sunlight and precursormolecule in skin makevitamin D. It is

essential for preventing osteoporosis and rickets, a condition that causes bone deformities and
result from a deficiency of vitamin D

Protection- The skin covering most of the body it acts as a physical barrier, but it provides
very effective protections against invasion by bacteria and other foreign matter. The
thickened skin of the palm and soles protect against the effects of the constant trauma that
occurs in these area

Absorption and secretion - The skin is involved in the absorption of water- soluble molecules
and excretions of water and sweat

Fluid balance- The stratum corneum, the outermost layer of the epidermis but the capacity to
absorb water, thereby preventing an excessive loss of water and electrolytes from the internal
body and retaining moisture in the subcutaneous tissues. When skin is damaged, as occurs
with a severe burn, large quantity of fluids and electrolyte may be lost rapidly. The skin is not
completing impermeable of water. Small amount of water continuously evaporates from the
skin surface. This evaporation called insensible perspiration

Temperature Regulation- The body continuously produces heat as a result of the mechanism
of food which produces energy. This heat is dissipated primarily through the skin. Three
major physicalspossess are involved in loss of heat from the body to the environment

Sweating- is another process by which the body can regulate the rate of heat loss. Sweating
does not occur until the core body temperature exceeds 37

Immune response functions-Recent research has confirmed a definite action of Langerhans

cells (specialized cells in the skin) facilitating the uptake of igE- associated allergens. This
plays a very important role in the pathogenesis of atopic dermatitis and other allergic diseases
such as asthma and allergic rhinitis. These findings support the concepts of a systemic
regulator mechanism as a trigger for allergic diseases and suggest that this trigger can be
aggravated by local inflammations of atopic eczema
ASSESMENT OF INTEGUMENTARY SYSTEM

Assessment of the integumentary systems includes a comprehensive health history and

physical examination. The history identifies any symptoms related to the integumentary
system, risk factors for skins problems and the presence of diseases in other systems that
could contribute to skin problem. The physicals examinations identify the current conditions
of the integument, including any abnormal functions throughout the assessment, be attentive
to sign and symptoms of both actual and potential problems of the integumentary

Health historythe health history includes subjective data obtaining biographical data and
asking questions about the patient’s current health past, and family psychosocial history.

HEALTH HISTORY

Past health history: - past health history will indicate previous trauma, surgery, or prior
disease that involves the skin. The nurse should determine if the patients has noticed of
dermatologic manifestations of systematic problems such as jaundice, wound healing,
cyanosis and pallor anaemia. Specific information’s related to food sensitivity, pet allergy
drug allergy skin reactions insect bites or prolonged exposure to u v rays and radiations and
chemotherapy treatment
Medications: -the patients should be questions about related problem. that occurred as a
results of taking prescriptions or over the counter (o,t,c).medications . a thorough medications
history of the patients it will help the nurse or the physician to know the in-depth cause of
skins resections and its developed
Surgery or other treatments: - it is important to determine if any surgical procedures.
Including cosmetics surgery, were performed on the skin if biopsy was done the result should
be recorded. Any treatment specific for a skin problem such as photo therapy, or for a health
problem, such as radiations therapy should also be noted. In addition, treatment undergone
for primarily cosmetic purposes, such as tanning booth use cadre resurfacing, or cosmetic
peels should be documented
Functional health patterns: - health management patterns. The nurse should ask about the
patients’ health practices related to the integumentary systems such as self-care habits related
to daily hygiene. Assessment the frequency use and sun protections and the use of personal
care products and sun protection and the used of personal care products (e.g. shampoos,
moisturizing agents and cosmetics products medications used for treating hair loss should
also be noted
Nutritional metabolic pattern: - the nurse should ask the patients about the changes in
conditions of skins, hair, nails, and mucous membrane and weather they are related to dietary
changes. a diet history to reveal the adequacy of nutrients essentials to healthy skin such as
vitamins a, d, e and c; dietary fats and protein. Food allergies that cause skin reactions.
excessive or absent sweating should be noted, poor and wound healing
Eliminations pattern: -the patients should be assessing about the skin such as dehydrations
oedema and pruritic which can indicate alterations in fluids balance
Activity exercise pattern: - information’s should be obtained about environmental hazards
in relation to hobbies and recreational activities, including exposure to known carcinogens,
chemicals irritants and allergens it also important to assess any changes occurs in skin during
exercise and other activities
Sleep rest pattern: - the patients should be assessing about rest and sleep disturbances
caused a skin conditions for example pruritic (itching) can be distressing and caused major
alterations in normal sleeping patterns. Also, poor sleep can be resulting tiredness as often
reflected in patients face by dark circles under the eyes and decreased firmness in the facial
skin
Cognitive perceptual pattern: - assessment should also be made based on the feelings
related to sad ness, anxiety, despair or altered body image in relations to the patient’s skin
conditions because this will occur with visible skin problems such as acne and psoriasis
Role relationship patterns: - it is important to determine how the patients skin conditions
affects relationship with family members, peer and work associates it also assessed based on
the effects of the environmental factors on skin such as occupational exposures to irritants,
sun and unusually cold and unhygienic conditions
Sexuality reproductive pattern: - the nurse tact fully questions and assess the patients skin
conditions. It also important for the nurse to note down on female patients related to possible
therapeutic interventions for examples isotretinoin (acutance) used to treat acne and Fluro
plex used to treat actinic keratoses are tetra genic drugs that may cause abnormal to foetal
development
Coping stress tolerance pattern: - it is important the nurse to assess the patients about how
the patients can cope up with stress and how the stress may play in creating or exacerbating
in skin conditions
Value- belief pattern: - the patients should ask about cultural, religious beliefs that could
influence the perceptions of self-image as related to the skin conditions. Assessment should
be made of values and beliefs that night influence or limit the choice of treatments options.

OBJECTIVE DATA
Physical examinations: - primary skin lesions develop on previously un altered skin.
secondary skins lesions that change with time or occurs because of factors such as scratching
or infections
The following are some principles conducting using skin assessment they are follows: -
 Having a private examinations room of moderate temperature with good light, a room
with exposure to day light is preferred
 Ensure that the patients are comfortable and in a dressing gown that allows easy
occurs to all skin areas
 It should be in a systematic and proceeds from head to toe
  Perform a general inspection and then a lesion specific examination
 Use the metric system when taking measurements
 Use appropriate terminology and nomenclature when reporting of documenting

Inspections: - the skin is inspecting for general colour and pigmentations, vascularity,
bruising, presence of lesions or discolouration’s. The skin colour it depends on the amount of
melanin (brown) carotene(yellow) oxyhaemoglobin (red) and reduced haemoglobin (blush
red) present at particular time. The most reliable areas in which skin can be inspect are
erythema, cyanosis, pallor, and jaundice are the areas of least pigmentations such as sclerae,
conjunctiva, nails beds, lips and buccal mucosa. The true skin colour is best observed in
photo protected areas such as buttocks
The skins are examining for possible problems related to vascularity such as areas
of bruising and vascular reactions to directs pressure should be noted if lesions are found on
skin inspect the colour, size, shape and distributions. During systematic inspections it is
important to note any unusual odour, skins sites that contain lesions. Such as rashes that area
colonized with yeast or bacteria, and are often found in areas e.g. axillary and groin
Inspections of hair: - also include on examinations of all body hair note the distributions
texture and quality, quantity of hair. Changes in the normal distributions of body hair growth.
May indicate an endocrine or vascular disorder.
Other changes
Male pattern hair distributions may be seen in some women at the time of menopause when
the hormone estrogen is no longer produced by ovaries. In women with hirsutism, excessive
hair growth may grow on face, chest, shoulder, and pubic area. If menopause is ruled out as
the underlying cause change related to pituitary or adrenal dysfunctions must be investigated
Inspections of nails: -it includes a careful examinations of nails shapes, thickness curvature
and surface. Any groves, pitting, ridges or detachment from nail bed should be noted

Palpations: the skin is palpated to provide information’s about temperature, turgor and
morbidity, moisture and texture. Temperature of the skin is best observed by using the back
of the hands. The skin should be warm without being hot the temperature of the skin
increases when bloods flow into the dermis the temperature increase in case of burns and
inflammations. A decrease temperature may occur when shocks and other circulations
problems moisture of skin or dryness of skin increased with high humidity. On palpations the
nurse should assessed flacking, scaling and cracking
SKIN INFECTIONS

Bacterial infections

Gram positive staphylococcus aureus and beta haemolytic streptococci cause bacterial
infections. Primary infections occur if break presents in skin present secondary infections
occurs if it followed already damaged skin or as a sign of systematic infection

Causing factors: moisture, obesity, skin disease, antibiotics and chronic diseases

Common bacterial infections

Impetigo it is superficial skin infections cause by staphylococci, streptococci.it involves

exposed areas of body, face, hands, neck extremities

 Primary impetigo occurs due to poor hygiene and malnutrition’s

 Secondary impetigo occurs due to pediculosis captis (head lice scabies, herpes
simplex, insects bite or eczema)

Bullous impetigo: staphylococcus aureus causes this superficial infection.it is characterised

by information of bullae from original vesicles

FOLLICULITIS is an inflammations of hair follicle, caused by staphylococcus aureus. it is

present in area where frictions, moisture, rubbing or oil is more. poor nutrition prolonged skin
moisture. Infections begins at opening of follicle and extends down into follicle.

FURUNCLE: furuncle is also called boils. It is acute inflammation of one or more follicles
and spreading’s into the dermis. It is caused by staphylococcus aureus it mostly occurs on
back of neck, thigh, axillae perineum or on buttocks

CARBUNCLES: it causes by staphylococcal cause carbuncles. It is multiple interconnected

furuncles. Lesion begins as firm mass in subcutaneous tissues and lower dermis. Then it
became swollen painful and have multiple openings to skin surface.it is found on back of the
neck upper arm buttock and lateral thighs it is mostly occurs in hot and humid climate

CELLULITIS: is a localized infection of dermis and subcutaneous tissue. It can be

secondary complications, or a primary disease mainly cause by staphylococcus aureus

ERYSIPELAS: this is superficial infections of skin primarily involved dermis caused by

group a b haemolytic streptococcus. Its appears on face, ears and lower legs commonly

VIRAL INFECTIONS: are common and can occurs anywhere in body

WARTS: are caused by human papillomavirus (HPV). Warts found on mucous membrane,
skin of human and genital skins of humans
HERPES ZOSTER (SHINGLES): this viral infection caused by varicella zoster. This
infection occurs in dermatome sections of skin. Mainly occurs in immune compromised
patients, radiotherapy, chemotherapy, transplant and HIV patients

FUNGAL INFECTIONS: fungi are free living plant like organism that live in the soil, on
animals and plants. Fungi that cause superficial skin infections are called dermatophytes live
on stratum corenum, hair and nails

COMMON FUNGAL INFECTIONS

DERMATOPHYTOSES (tinea): commonly called ringworm infections

Mode of transmission: fungal infections transmitted by direct contact with infected person or
animals or by inanimate objects such pillow cover towel

CANDIDIASIS: it is an infection cause by candida albicans, yeast like fungus. Its normally
found on mucous membranes on skin in vagina and in gastro intestinal tracts

INFESTATIONS DISORDERS: infestation of skin by parasites (lice and mite) are called
parasitic infestations

PEDCULOSIS: it is an infestation with lice, this parasite lives on the blood of an animal or
human host. Louse is oval organism with stylet that pierce skins and anticoagulant is present
in the saliva that prevent the clotting of host blood. lice eat blood of the host. Female louse
lay eggs on shaft of hair and becomes mature and dies in 30-50 days. There are three types of
pediculosis- pediculosis cepitis, corporis and pubis

SCABIES: this is parasitic infestations. Sarcoptes scabies mites cause scabies. Scabies is
found between the fingers, inner surfaces of the wrist and elbow the axillae, the female nipple
the penis,

INFLAMMATORY DISORDERS OF SKIN

DERMATITIS: it is inflammations of skin characterized by erythema and pain or pruritus. It

may be acute or chronic.

Type of dermatitis a) contact dermatitis b) allergic contact dermatitis

ACNE DISORDER: is a common disorder of pilosebaceous (hair and sebaceous) structure,

as they open to the skins surface through por. These glands produce sebum, a lipid substance
it may inflammatory and non-inflammatory

PEMPHIGUS VULGARIS: it is a chronic disorder of skins and oral mucous membrane

characterised by blisters (bullae)formations. It is autoimmune disorder and associated with
igG antibodies and HLA-A10 blisters (bullae) forms from antigen-antibody reactions
NON-INFECTIONS INFLAMATORY DERMATOSES

PSORIASIS: is a chronic, non-infections, recurrent erythematous inflammatory disorder

involving keratin synthesis. It is characterised by raised, reddened round circumscribed
plaques covered by silvery white scales. Its occurs in any age.

PRESSURE ULCERS: bed sore and decubitus ulcers are the other name of pressure under.
Decubitus comes from Latin. Decumbere to lie down. They are common in bed ridden person
that is why that called pressures ulcers/ bedsore

Pressure ulcers are ischemic lesions of skins and underline tissue caused by unrelieved
pressure that alters the flow of blood lymph. Blood flow alterations cause tissue necrosis and
ulcerations mainly developed on bony prominence due to high pressure on them.

MAGLIGNANT MELANOMA: is a cancer of melanocytes, which produce melanin. It is

most deadly cancers of skins. It has the ability to metastasize to any other organs including
brain and heart

ALOPECIA: it is a loss of hair or baldness

DIAGNOSTIC TESTS

Laboratory test

Some dermatologic conditions can be elevated by laboratory test of microscopic culture

Microscopic:

a) Sample taken by scraping, swabbing or aspirating a lesion is transferred to a glass

slide for observation
b) Direct observations of scraping which mixed with mineral oil to detect scabies, mites.
c) Potassium hydroxide may be added to skin scrapping on a glass slide and heated to
dissolve skin cells to detect hyphae and spores in fungal infections
d) Gram stain may be performed to tentative identify bacteria in certain skin infections

Drainage from lesions may be cultured on a specific media to detect causative organism and
sensitivity to antimicrobial therapy: also, portions of skin hair and nail may be submitted for
fungal culture. Usually take 24 to 48 hours for results fungal culture may take 4 to 5 weeks.

Other tests

Patch testing: - patch test is an office procedure done to determine if patients are sensitive to
contact materials. Material are applied in patches to the skin and checked for reactions 48
hours after applications and possibly again in one week. Erythematic, swelling, papules, and
vesicles indicate an allergic contact dermatitis is rather than an irritant contact dermatitis or
no reactions

Skin biopsy: -Perform to obtain tissue for microscopic examination a skin biopsy may be
obtained by scalpel excision or by a skin punch instruments that removes a small core of
tissue. It is performed on skin nodules, plaques, blisters and other lesions to rule out
malignancy

Immunofluorescence: -it is designed to identify the site of immune reactions

Immunofluorescencetesting combines an antigen or antibody with flouroschrome dye.
Antibody can be made fluorescent by attaching them to a dye direct Immunofluorescence test
on skin are technique to detect auto antibodies

Skin scrapings: - Tissue samples are scraped from suspected fungal lesions with a scalped
blade moistened with oil so that the scraped skin adheres to the blade. The scraped transferred
in to a slide with a covered slip and examine microscopically the spores andhyphaeof
dermatophyte infections can be visualized.

Tranck smear: - the trank smear is a test used to examine cell from blistering skin conditions
such as herpes zosters herpes simplex and all form of suspected lesion

Wood light examinations: - is that type of examinations that produce long wave ultra-violet’s
rays which results in a characteristic dark purple of fluorescence it is best in dark room where
is possible to differentiate dermal from epidermal lesion and hypo pigmented and hyper
pigmented

Clinical photographs: - it is used to document the nature and the extent of the skin conditions
and is used to determine the progress of treatment

TREATMENT:

Managements of clients with integumentary disorders

Medical management:

Common antibiotics include dicloxacillin, erythromycin and tetracycline.

Antifungal agents include fluconazole and itraconazole. Terbinafine is an oral antifungal

medicine which used to treat fungal infections of nails

Alclometasone it used for atopic dermatitis, allergic dermatitis kiss type allergy and skin
itching.

Allantoin: used to treat for psoriasis and other skin diseases.

Amcinocide: used to treat for skin inflammations and itching.

Amorolfine: is a topical antibiotic treat for toenail infections and skin fungal infections
SURGICAL MANAGEMENT:

 Plastic surgery: plastic surgery can involve a number of different technique to move
and manipulate body tissue. Plastic surgery used to be confined to a procedure called
a skin grafting.
o Flapssurgery is a technique in plastic and reconstructive surgery where any
type of tissue is lifted from a donor site and moved to a recipients site with an
intact blood supply this is similar to but different from a graft, which doesn’t
have an intact blood supply and therefore relies on growth of new blood
vessels.

o Cryotherapy is a pain treatment that uses a method of localized freezing

temperatures to deaden an irritated nerve. It is also used as a method of
treating localized areas of some cancers (called cryosurgery) such as prostate
cancer and to treat abnormal skin cells
o Wound closure: - wound generally must be closed for proper healing it is
typically done with sutures or using thread or staples it depending on the type
and locations of wound

 Skin surgery like electrosurgery: Electro surgery is the applications of a high

frequency (radio frequency) alternating polarity, electrical current to biological tissue
as a mean to cut, coagulate, desiccate, or fulgurate tissue.

NURSING DIAGNOSIS:

1. Impaired skin integrity related to wound, skin breakdown

Expected outcomes: To improve skin integrity of a patients as evidence by skin breakdown

and wound

Nursing Intervention:

 Assess site of impaired, wound and skin breakdown

 Provide proper care and proper dressing to the breakdown area
 Advice the client to apply ointment regularly as prescribed

2. Risk for impaired skin integrity related to immobility, poor nutrition, poor
circulations.

Expected outcomes: To improve mobility as evidence by poor circulations, poor nutrition’s.

Nursing interventions:

 Assess patient’s ability to move, turn over in bed, move from bed to chair
  Assess patient’s nutritional status, including weight, weight loss and serum
albumin levels.
 Checked clean, dry, and moisturize skin, especially over bony prominences

3. Health -seeking behaviours, related to the fear of skin cancers

Expected outcome: To reduce fear and anxiety of a patients as evidence by

behavioural aspects

Nursing interventions:
 Assess the fear and anxieties of the patients and relative
 Provide health educations regarding the caused and preventions risk of cancers
 Provides psychological support

4. Impaired skin integrity related to pressure ulcer

Expected outcomes:to prevent the risk of pressure ulcers as evidence by changing

positions, improve health care status

Nursing interventions

 Assess the specific risk factors of pressure ulcers, and pressure point
 Assess the client’s nutritional status including weight, weight loss and serum
albumin levels

5. Impaired skin integrity related to surgical incisions

Expected outcomes: To maintain depressed area remain dry and intact as evidence
increase risk of infections

Nursing interventions:

 Support and instruct client in incisional support when turning, coughing and deep
breathing
 Provide incision periodically noticing hematoma formations and bleedings
 Provide foam, water, or air mattress as indicated

NURSING RESPONSIBILITY:

 Monitor locations durations and intensity of pain

 Teach the client about the importance of good personal hygiene and maintaining good
nutritional status
 Provide health education regarding the cause and treatment of diseases condition
 Teach the patients to wash linen in hot water
 Educate the client to take prescribed medicines regularly
 Teach the client not to share clothes
 Teach the client to avoid tight clothes such as jeans
 Wear cotton under wear
CONCLUSIONS
Skin is one of the most important system in our body it’s protect the body from the outside
world and overall harmful substances it acts as a barrier between the internal organs and the
external environment and participates in various vital body functions. The skin is contiguous
with mucous membrane it plays a very important role it gives size shape to our body. Hence
it is important to our body system.

Source: Nursing standard. 9/19/2012, vol.27 issue 3, p35-45.8p.1 diagram

Author(s): Mclacfferty, Ella; Hendry, Charles; Farley, Alistair

ABSTRACTS

This article, which forms parts of the life sciences series examines the anatomy and
physiology of skin, also termed the integumentary system. Skin is composed of two main
layers, the epidermis and dermis. the structure of the epidermis and dermis are described, and
their functions are discussed. accessory structures, such as nails and hair are also considered.
although many diseased conditions of the skin exist some common conditions like psoriasis,
decubitus ulcers alopecia are discussed here

BIBLIOGRAPHY:

Books:

 Suzanne C.and et al.Textbook of medical surgical nursing

11 Editions. Wolters Kluwer Pvt Ltd 2010 volume 2 1927-1935
th

 Nettina M.S LippincottManual of NursingPractice9 th edition. New Delhi. Wolters

Kluwer Pvt Ltd .2010

 Black. M.J. Medical surgical Nursing- clinical management for positives outcomes 7 th
Editions.Reed Elsevier India Pvt Ltd New Delhi
  Levis |Heitkemper | Dirksen | Bucher O’Brein. Medical- surgical Nursing. New Delhi.
Reed.Elsevier India Pvt Ltd. 2013.

website

 https://en.m.wikipedia.org
 https:/ Goggles. Org