K.G.M.

U COLLEGE OF NURSING

TOPIC- CASE STUDY ON PNEUMONIA

SUBJECT-ADVANCE NURSING PRACTICE

SUBMITTED TO: SUBMITTED BY
Mrs. Reena Raj Ms. Jyoti verma
Clinical Instructor M.Sc Nursing 1st Year
KGMU College of Nursing KGMU College of Nursing
Patient Bio-Data
Name - Ankit Singh
Age - 4 years
Sex - male
Religion - Hindu
Father’s Name - Mr. Ram Singh
Occupation - shopkeeper
Education - graduation
Date of Admission - 1/2/19
Mother’s Name - Mrs. Soni
Occupation - Housewife
Education - 12th pass
Informant - Mother
Diagnosis - Pneumonia
Surgery - absent
Treated by - Dr. Sarika gupta

Presenting Complaints: According to the mother the presenting complaints are:-

 Difficulty in swallowing from 5 days.
 Cold from 5 days
  Cough from 3 days
 Fever from 5 days

History of present illness:

a. Approximately time of onset: Patient is suffered from this condition from 5 days.
b. Mode of onset: patient’s condition is severe when she admitted here but now her condition is moderate.
c. Sequential history of appearance of complaints: patient is suffered from Difficulty in swallowing from 5 days, Cold from 5 days, Cough
from 3 days, Fever from 5 days, then she went to near clinic but he had no any relief then she come kgmu and consult with Dr.sarika
gupta as per her advice he admitted in PICU ward and now her condition is better than before.
d. Therapy/ treatment received so far: ankit Singh brought to KGMU hospital and at present he is on intravenous fluid 50 ml normal saline
8 hourly, tab PCM 150 mg 12 hourly orally,inj. Metrogyl 200ml once a day intravenous, inj. Brodiclor 5 ml twice a day intravenous, cap.
Cetgel 10 mg 8 hourly, inj. Pantop 10 ml once a day intravenous.

Past history:
Past medical history- Patient has no past medical history.
Past surgical history-patient has no past surgical history.

Birth history

Antenatal history
Mother taking adequate nutrition at the time of pregnancy: Mother said that she has taken adequate nutrition during pregnancy and she is non-
vegetarian.
Registered in health facility: She did her registration in queen marry hospital during pregnancy.
Consuming iron and folic acid: She had taken iron and calcium tablet during pregnancy.
Regular antenatal checkups: she has only 3 antenatal visits.
Natal history:
Type of delivery: Normal vaginal delivery
Baby cried at birth: Soon after birth baby cried immediately.
Institutional delivery: She delivered normally at queen marry hospital, Lucknow.
Weight of the child: 3.0kg

Postnatal history:
Condition of the mother: After delivery condition of mother was satisfactory.
Condition of baby: It was satisfactory
History of any infections, PPH or any other problems: Not present PPH or any other problem in mother after the delivery.

Personal history
Personal hygiene of the child: Mother maintains proper care of the child before the admitted in hospital but now also she is maintaining the
proper hygiene of the patient.
Response of child towards illness: Child is irritable and crying but now normally response with the staff and family member.
Response of parents towards illness: parents are having anxiety and fear about their child condition.

Developmental history: Ankit singh is normal developmental history such as done all physical activity, short interest span, use parts of
speech correctly..

Family History
History of contact illness: No history of any communicable or non-communicable illness in the family such as tuberculosis, HIV,
Diabetes, hypertension etc.
History of similar ailment in the family: No similar history presents in the family.
History of consanguinity: No history of consanguity in the family.
Birth order: he is the first baby of her mother.
Number of siblings: Ankit Singh is only child of her parents.
Illness: Nobody is having similar illness or any other illness in the family, but his great grandfather was having tongue cancer.
Any death in the family: Great grandparents are died in family.

Socio economic history

Family type: Ankit Singh living in a joint family.
Who looks after the child: Grandparents and father.
Housing condition: housing condition is normal because she belongs from a middle class family about more needed facilities occur in her house.
Overcrowding: there is no overcrowding in the family because everyone has a separate room.
Town: she lives in an urban area.
Water source: In her home proper water supply, they are using hand pump.
Smoking among family member: His father is non smoker and eating beetles and nuts in the family.
Schooling of the child: Still he didn’t started his schooling
Interactive behaviour/interest of the child: Child is interesting in an indoor plays and interested in seen cartoons movies.

Nutritional history
Breast feed/ top feeds/mixed mode of feeding: ankit Singh is on mixed mode of feeding but now he is on NPO.
Vegetarian/ Non vegetarian: Patient is vegetarian.
Dietary intake before and during illness: before the illness patient take proper diet like rice, green vegetables, pulses and roti but now she is NPO
due to illness.

Immunization History: Child had receive all vaccine till date like BCG, oral polio vaccine zero,1st 2nd 3rd and booster doses, hepatitis B
1st ,2nd,and 3rd doses, DPT 1ST ,2nd, 3rd and booster doses ,measles and TT dose.

Any known allergies: patient having no any type of allergies.

Blood transfusion: Child has not received blood transfusion so far.

PHYSICAL EXAMINATION

General examination
General condition: Conscious
Decubitus: not present.
Built and nutrition: weight in kg/height in m2 (39/149.8m2=30.9)3
Pallor: no pallor found
Icterus: Jaundice is not present
Cyanosis: Cyanosis is not found.
Oedema: No Oedema present
Clubbing of nails: child is not having clubbing of nails.

Vital signs
Temperature: 101.2 F
Pulse: 90 beats/ minute
Respiratory rate: 32 beats/minute
Blood pressure: 100/60 mm/hg

Anthropometric measurement
Height/length: 37
Weight: 32 kg
Head circumference: 49cm
Abdominal girth: 38 cm
Mid arm circumference: 14 cm
Condition of skin: child’s skin is soft, but dry, no any petechiae, redness, bruises, scratches, blunt injury or open wound is found.

Head
Condition of hairs: colour of hair is black in colour, no dryness, pediculosis, dandruff or split ends present.
Head shape: head is bulge.
Head bossing: not present.
Fontanels: both the fontanels anterior and posterior are present but fontanels are bulge.
Cranial sutures: present no any other deformities present.
Characteristics facies: symmetric

Eyes: eyes are not properly open, and eye discharge is present.

Ear: Both the ears are symmetrical in shape and size, no wax, ear tags or hearing aids present.

Nose: secretion is present but no septal deviation, nasal congestion or flaring present.

Mouth: lips is dry, and cracked, mucus membrane is not healthy.

Neck: Neck is normal in shape, trachea is in midline and webbed. Rigidity, thyroid, neck vein distention lymph nodes not present.

Condition of nails: nails are pink in colour and it is normal in shape, brittle nail is not found.

Systemic circumference

A. Respiratory System
1. Respiratory rate: 32 beats/minutes
2. Use of accessory muscles: Not present
3. Types of breathing: breathlessness
4. Movements/symmetry: asymmetrical movements are present.
5. Chest wall deformity: deformity is not present
6. Neck vein distension: Neck vein is not distended
7. Trachea midline: Trachea is in midline position
8. Air entry: Air entry is not equal in both the lungs.
9. Any other audible sound: no any other abnormal sounds like grunting, wheezing present.

B. Cardiovascular system
1. Apex beat: it is normal
2. Any murmur: S1 and S2 sound heard and it is normal no S3 and S4 sound heard.
3. Any other sounds: not present.

C. Abdomen
1. Shape: shape is distended and round in shape.
2. Prominent veins: Veins are distended and visible.
3. Visible peristalsis: Not present.
4. Bowel sounds audible: Not audible
5. Distension: No any abdominal distension.
6. Abdominal wall rigidity/ guarding: Abdominal walls are normal.

D. Musculo skeletal
No any skeletal defect like club foot, talipes present. Movements are normal no any redness, tenderness or swelling present.

E. Gastro intestinal system

Child having no diarrhoea, haematosis or jaundice present but vomiting present in child.

F. Central Nervous system

1. General appearance: Generally, child is looking dull and weak. No any other congenital disorders are seen.
2. Posture: generalized flexion is seen; the neck extremities are flexed.
3. Gait: Flexion and extension present.
4. State of sensorium: Present.
5. Orientation/ speech/intellect/memory: oriented to time, place and person.
6. Meningeal irritation: absent
7. Abnormal movements: Not present
8. Sensory: child having sensation to stimulus either touch or pain.

Growth and development assessment

S. No Items to be assessed
Yes No Remark

The weight of
1. Physical development child is
No appropriate
 Weight is 32kg.
according to
 Pulse is 90beats/min
age
 At about 12 years molar erupts
Motor development
2. o Gross motor Yes
o Enjoy all physical activities.
All these motor
o Balances on one legs with eyes closed. development
o Fine motor are present in
o Dressing and grooming skills develop child.
o Movements are more graceful
Intellectual movement
3.
 Use problem solving method.
 Interested in ‘why’ and ‘how’. Yes
Language
 Short interest span. development
are present in
Language development child
4.  Oral vocabulary of 7200 words.
Yes These
 Uses parts of speech correctly.
psychosocial
5. Psychosocial development- developments
o Has greater self control. are present in
o Still fears the dark. child.

Immunization status
S. No. Vaccines Time of administration Child status
 1. BCG At birth Given
2. OPV-‘0’ Dose At birth Given
3. Hepatitis-B 1st dose At birth Given
4. DPT 1st dose 6 weeks Given
5. OPV 1st doses 6 weeks Given
6. Hep b 2nd dose 6weeks Given
7. DPT 2nd dose 10 weeks Given
8. OPV 2nd dose 10 weeks Given
9. DPT 3rd dose 14 weeks Given
10. OPV 3rd dose 14 weeks Given
11. Hep B3rd dose 14 weeks Given
12. Measles 9 month Given
13. DPT 1st booster 16-24 month Given
14. OPV booster dose 16-24 month Given

Nutritional assessment: child was on mixed mode feeding, but at present she is NPO and at is on intravenous fluid.
Investigation
HAEMATOLOGY NORMAL VALUES PATIENT’S VALUES REMARKS
Haemoglobin 11.5-15.5gm/dl 8.2 Decreased

TLC 4000-11000 cells/mm3 14800 Increased

DLC
Neutrophils
Lymphocytes 40-80% 82%
Eosinophils 20-40% 49%
Increased
Monophils 1-6% 7%
basophils - 2%
- 1%
Platelet count 1.5-4.5 cells/mm3 4.1 Normal
BIOCHEMISTRY

Serum urea 10-45mg/dl 54.5 Increased

Serum creatinine 0.5-1.5mg/dl 2.24 Increased
Serum sodium 135-145mmol/L 122.7 Decreased
Serum potassium 3.5-5.3 3.32 Decreased
Serum calcium 4.5-5.5 3.32 Decreased
LFT
SGOT
0-40 IU/L 351
SGPT
0-40 IU/L 432
Sr. Bilirubin
0-0.4 mg/L 0.65
Alkaline phosphate Increased
50-270 IU/L 388
Special investigation
No recently special investigation of the patient.

ANATOMY AND PHYSIOLOGY OF LUNGS

INTRODUCTION
The lungs are the primary organs of respiration in humans and many other animals including a few fish and some snails. In mammals and most other
vertebrates, two lungs are located near the backbone on either side of the heart.

The lungs are located in the chest on either side of the heart in the rib cage. They are conical in shape with a narrow rounded apex at the top and a
broad base that rests on the diaphragm. The apex of the lung extends into the root of the neck, reaching shortly above the level of the sternal end of
the first rib.

The front and outer sides of the lung face the ribs, which make light indentations on their surfaces. The bottom of the lungs is smooth and rests on the
diaphragm, matching its concavity. The medial surface of the lungs faces towards the centre of the chest, and lies against the heart, great vessels, and
the carina where the two main bronchi branch off from the base of the trachea.

Gross anatomy

Both lungs have a central recession called the hilum at the root of the lung, where the blood vessels and airways pass into the lungs. There are also
bronchopulmonary lymph nodes on the hilum.

The lungs are surrounded by the pulmonary pleurae. The pleurae are two serous membranes; the outer parietal pleura line the inner wall of the rib
cage and the inner visceral pleura directly lines the surface of the lungs. Between the pleurae is a potential space called the pleural cavity containing
pleural fluid. Each lung is divided into lobes by the invaginations of the pleura as fissures. The fissures are double folds of pleura that section the
lungs and help in their expansion.

LUNG VOLUME
Lung volumes and lung capacities refer to the volume of air associated with different phases of the respiratory cycle. Lung volumes are directly
measured; lung capacities are inferred from lung volumes.

The average total lung capacity of an adult human male is about 6 litres of air.

Four types

1. Tidal volume

2. Inspiratory reserve volume

3. Expiratory persevere volume

4. Residual volume

PNEUMONIA
INTRODUCTION
Pneumonia is an infection of the lower respiratory tract that involves the airways and parenchyma with consolidation of the
alveolar spaces.
• The term lower respiratory tract infection is often used to encompass bronchitis, bronchiolitis, or pneumonia or any
combination of the three, which may be difficult to distinguish clinically.
• Pneumonitis is a general term for lung inflammation that may or may not be associated with consolidation.
Lobar pneumonia describes "typical" pneumonia localized to one or more lobes of the lung in which the affected lobe or lobes
are completely consolidated.
• Bronchopneumonia refers to inflammation of the lung that is centered in the bronchioles and leads to the production of a
mucopurulent exudate that obstructs some of these small airways and causes patchy consolidation of the adjacent lobules.
• Interstitial pneumonitis refers to inflammation of the interstitium, which is composed of the walls of the alveoli, the alveolar
sacs and ducts, and the bronchioles. Interstitial pneumonitis is characteristic of acute viral infections, but also may be a chronic
process.
DEFENSE MECHANISM
Lower airways and secretions are sterile as a result of a multicomponent cleansing system.
• Airway contaminants are caught in the mucus secreted by the goblet cells.
• Cilia on epithelial surfaces, composing the ciliary elevator system, beat synchronously to move particles upward toward the
central airways and into the throat, where they are swallowed or expectorated.
• Polymorph nuclear neutrophils from the blood and tissue macrophages ingest and kill microorganisms.
• IgA secreted into the upper airway fluid protects against invasive infections and facilitates viral neutralization.
RISK FACTORS
Risk factors for lower respiratory tract infections include:
• Gastroesophageal reflux
• Neurologic impairment (aspiration)
• Immune compromised states
• Anatomic abnormalities of the respiratory tract
• Residence in residential care facilities for handicapped children
• Hospitalization, especially in an ICU or requiring invasive procedures.
ETIOLOGY
Although most cases of pneumonia are caused by microorganisms,(infectious)
non-infectious causes include:
• Aspiration of food or gastric acid, • foreign bodies, • hydrocarbons, and lipoid substances, • hypersensitivity reactions, and •
drug- or radiation-induced pneumonitis.
The infectious agents that commonly cause community-acquired pneumonia vary by age • the most common causes are RSV in
infants, • respiratory viruses (RSV, parain-fluenza viruses, influenza viruses, adenoviruses) in children younger than 5 years
old, and • M. pneumonia and S. pneumonia in children older than age 5. • M. pneumonia and C. pneumonia are the principal
causes of atypical pneumonia. • Additional agents occasionally or rarely cause pneumonia as hospital-acquired pneumonia, as
zoonotic infections, in endemic areas, or among immune compromised persons.
CAUSES
Causes of pneumonia in immune compromised persons include:
• Gram-negative enteric bacteria
• Mycobacterium (M. avium complex)
• Fungi (aspergillosis, histoplasmosis)
• Viruses (CMV)
• Pneumocystis jirovecii (carinii).
• Pneumonia in patients with cystic fibrosis usually is caused by:
• S. aureus in infancy
• P. aeruginosa or Burkholderia cepacia in older patients.
CLINICAL MANIFESTATION
BOOK PICTURE PATIENT PICTURE
Fever Present
chills Present
tachypnea Absent
cough Present
malaise present
pleuritic chest pain Absent
Difficulty breathing or shortness of breath. Absent

DIAGNOSTIC EVALUATION
Serologic tests are not useful for the most common causes of bacterial pneumonia.
The WBC count with viral pneumonias is often normal or mildly elevated, with a predominance of lymphocytes,
• whereas with bacterial pneumonias the WBC count is elevated (>20,000/mm3) with a predominance of neutrophils.
• Mild eosinophilia is characteristic of infant C. trachomatis pneumonia
Blood cultures should be performed to attempt to diagnose a bacterial cause of pneumonia.
• Blood cultures are positive in 10% to 20% of bacterial pneumonia and are considered to be confirmatory of the cause of
pneumonia if positive for a recognized res A pneumolysin-based PCR test for pneumococcus is available at some centers and
may aid in the diagnosis of pneumococcal pneumonia.
• CMV and enterovirus can be cultured from the nasopharynx, urine, or bronchoalveolar lavage fluid.
• M. pneumoniae should be suspected if cold agglutinins are present in peripheral blood samples; this may be confirmed by
Mycoplasma IgM or more specifically PCR.
• The diagnosis of M. tuberculosis is established by TSTs and analysis of sputum or gastric aspirates by culture, antigen
detection, or PCR. piratory pathogen.
• Urinary antigen tests are useful for L. pneumophila (Legionnaires ‘ disease).
OTHERS: Chest X-ray ultrasound

TREATMENT
Therapy for pneumonia includes:
• Supportive and specific treatment.
• The appropriate treatment plan depends on the degree of illness, complications, and knowledge of the infectious agent or of
the agent that is likely causing the pneumonia.
• Age, severity of the illness, complications noted on the chest radiograph, degree of respiratory distress, and ability of the
family to care for the child and to assess the progression of the symptoms all must be taken into consideration in the choice of
ambulatory treatment over hospitalization.
• Most cases of pneumonia in healthy children can be managed on an outpatient basis.
Although viruses cause most community-acquired pneumonias in young children, in most situations experts recommend
empirical treatment for the most probable treatable causes.
• Treatment recommendations are based on the age of the child, severity of the pneumonia, and antimicrobial activity of agents
against the expected pathogens that cause pneumonia at different ages.
• High-dose amoxicillin is used as a first-line agent for children with uncomplicated community-acquired pneumonia. third-
generation cephalosporins and macrolide antibiotics such as azithromycin are acceptable alternatives. Combination therapy
(ampicillin and either gentamicin or cefotaxime) is typically used in the initial treatment of newborns and young infants.
• Hospitalized patients can also usually be treated with ampicillin. The choice of agent and dosing may vary based on local
resistance rates. In areas where resistance is very high, a third-generation cephalosporin might be indicated instead. Older
children, in addition, may receive a macrolide to cover for atypical infections.
Pneumonia caused by S. pneumoniae presents a problem because of increasing antibiotic resistance.
• In contrast to pneumococcal meningitis, presumed pneumococcal pneumonia can be treated with high-dose penicillin or
cephalosporin therapy, even with high-level penicillin resistance.

NURSING DIAGNOSIS

1. Ineffective breathing pattern related to hypoxia as evidenced by our observation.

2. Parental anxiety related to child health condition as evidenced by verbalization.
3.Parentral knowledge deficit related to disease condition as evidenced by parents asking question related to disease.
4.Risk for infection related to surgical incision as evidence by redness around the incision.
 ASSESSMENT NURSING GOAL PLAN OF RATIONALE IMPLEMENTATION EVALUATION
DIAGNOSIS ACTION

Subjective data- Ineffective Patient will Assess respiratory rate, It gives base line data Respiration is rapid and Patient is able to
Patient says that i breathing attain normal depth, and effort, of patient. shallow, nasal flaring is breathe properly.
am not able to pattern related breathing including use of present.
breathe properly. to hypoxia as pattern accessory muscles, nasal
evidenced by within few flaring, and abnormal
Objective data- our mins. breathing patterns.
Restlessness observation.
Poor facial Position patient with
expression head of bed elevated, in a If improve lung Semi-fowler position is
Rapid and shallow semi-Fowler’s position. expansion given
breathing
Maintain an oxygen
administration device as O2 therapy is given by
ordered, attempting to It prevent hypoxia
simple O2 mask
maintain oxygen
saturation at 90% or
greater

Encourage slow deep

breathing using an
incentive spirometer as
indicated. Patient is advised for
It improves lung doing deep breathing
expansion exercise via spirometry.
Do suctioning if patient
is not able to clear her
secretions. Suctioning is done.
Do mechanical It is used to clear
 ventilation as per orders airway and make it
of doctor. patent.

It is used for
maintaining breathing
pattern.

ASSESSMENT NURSING GOAL PLAN OF RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSIS ACTION

ASSESSMENT NURSING GOAL PLAN OF RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSIS ACTION

Subjective data: Parental anxiety To reduce Assess the anxiety level Assessed the anxiety It helps to know the Reduced anxiety of
related to child anxiety of of child’s parent level of child’s anxiety level of parents the child’s parents
Parents are asking health condition child’s parents as evidence by
for wellness of as evidenced by parents their facial
the child and verbalization Encouraged parents to expression looking
Encourage the parents to Clarify the doubts of the normal.
about discharge ask doubt related to ask doubt related to parents.
child’s health condition child’s health
condition

Explained parents
Explain parents regarding health status Reduces anxiety & stress
regarding health status of of the child. of the parents.
the child.
Objective Data:
Parents are
looking anxious Given psychological
by facial Give psychological support to the child’s To reduce anxiety of the
expression. support to parents parents. parents.

Assessment Nursing Goal Planning Implementation Rationale Evaluation

Diagnosis

Subjective Data: Parental To enhance Assess family and Assessed family and It helps to know and plan Enhanced
knowledge knowledge parents level of parents for level of care accordingly knowledge to
Parents asked deficit related to to parents knowledge. knowledge, specific to parents regarding
question disease regarding health problem or disease condition
regarding disease condition as disease concern as evidence by they
condition. evidenced by condition says now child
parent asking condition is better.
question
regarding Developed teaching
Develop teaching plan plan about present It helps to provide
disease. about present health health problem knowledge to parents
 problem.
Provided opportunities
Objective Data: Provide opportunities for for child and family to It helps enhanced
child and family to ask ask questions, to knowledge in a better way
Parent asking questions. discuss about problem
question and to observe
regarding disease. demonstration of care

To give health
education through AV
aids like charts, flash
cards. Its provide knowledge in
Give health education. easy level related to
disease.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
Diagnosis

Risk for To reduce Assess child for changes Assessed child for It helps to know & plan Reduced the risk of
Subjective data- infection related the risk of in vital signs. changes in vital signs care to prevent it infection
poor personal infection and laboratory
hygiene as related to findings & signs of
Parents evidenced by poor infections
complaining verbalization personal
about redness, hygiene
itching on the
skin. Use universal
Use universal precautions precautions for To prevent from infection
for prevention of prevention of
infection. infection

Change the clothes of

Change the clothes of the child and provide
child. hygienic care to the To maintained the hygiene
child. of the child.

Administered
medication as
Objective Data: Administer medication as prescribed by the
prescribed by physician. doctor To prevent from infection
of the child.
On observation
child’s hygiene
was not
maintained
 HEALTH EDUCATION

DISCHARGE TEACHING FOR PARENTS: Parents should be taught prior to hospital discharge about education materials to help ensure
adequate child care and instructions regarding how to access healthcare providers for consultation. This information
should also be assessable at home. Discharge technique includes:
 Bathing and skin care
 Temperature assessment using a thermometer
 Teach about diet of the child
 Sleeping pattern of the child regulate

NUTRITION: To teach the parents give proper protein, carbohydrate and vitamin rich diet, and takes the diet properly in time in small amount
according to choice and nutrious diet.

PHYSICAL ACTIVITY: to teach the parents, maintain physical activity through the physical active and passive exercise to the child, move the
hand and rotate the feet.

ORAL HEALTH: To teach the parents for maintain proper hygiene of the child, like oral hygiene, nail care, back care, hair care for prevent the
infection of the child.

INJURY PREVENTION-to teach the parents to prevent any injury of the child because child is lack of consciousness. So do not leave them
alone in the room there is the fear of any injury with child.
MEDICATION-
Explained parents regarding importance of medication and its side effects. Advised not to stop medication without doctor’s prescription and try
to cover the full dose of medication.

PREVENTION
Minimizing the child’s exposure to disease Parents should be encouraged to
Avoid child exposure to large crowds, especially in cold and influenza season;
Cover coughs and sneezes; and use good hand washing technique. If the
child is exposed infection and any communicable diseases the caregiver should be alerted.

IMMUNIZATION
Explained parents regarding importance of immunization and adviced to get immunized your child according to age group.

FOLLOW UP CARE
At discharge, the family is given an appointment for the first visit in the office or clinic setting; a physician, nurse practitioner, or nurse
assessment is recommended
at 3–5 days of age, with subsequent follow-up visits for child.
 BIBLIOGRAPHY

1. Dutta Parul a, a text book of Paediatric Nursing, Third Edition,published by jaypee publisher 2010, Page no:-50-56

2. Marlow, Textbook of Paediatric Nursing, 2013, Page no.904.

3. Sharma rimple, Essentials of Paediatric Nursing,third edition published by jaypee publisher 2013, Page no.45-51

4. Pal Panchali , Textbook of Paediatric Nursing, 1st edition, 2016.

5. 5 Judith Hopper, April Hazard Vallerand, Davis’s Drung Guide for Nurses, 9 th Edition.