GOOD

AFTERNOON
CLASS PRESENTATION
ON
“Hepatitis”
Prepared by:
Anju Shah
Kalpana Kawan
BNS 3rd Year, 6th Batch
 General objective
At the end of this session, BNS 3 rd year students will be
able to explain about Hepatitis.
 Specific objectives
At the end of this session, BNS 3 rd year students will be
able to:
• Introduce Hepatitis.
• State the facts related to Hepatitis
• Enumerate the classification of Hepatitis
• Explain the types of viral hepatitis
• Describe the mode of transmission of Hepatitis.
• Explain the patho-physiology of Hepatitis
 Cont…
• List the clinical features of hepatitis.
• Enumerate the diagnostic evaluation of hepatitis
• Explain the medical management of hepatitis.
• Describe the preventive measures for hepatitis.
• Explain the nursing management of hepatitis
LIVER
 INTRODUCTION
Liver is the largest organ of the human body.
It weights 1.2-1.5 kg in the adult.
It is the chemical factory of the body.
It performs multiple functions which are
essential for life.
It has enormous reserve capacity and
marvelous regenerating power
Hence, even in the presence of advanced
anatomic changes all the liver functions need
not be completely impaired
Liver Functions
Metabolic function

Synthetic function

Excretory function

Detoxifying function

Secretory function

Storage function

Miscellaneous Function
Hepatitis
 Introduction
• The word “hepatitis” comes from the ancient
Greek word “hepar” meaning liver and
English word “itis” meaning inflammation.

• Hepatitis is the widespread inflammation of

liver cells resulting from viral or bacterial
infection, drugs, alcohol or chemicals toxic to
the liver and some metabolic and vascular
disorders.
Facts related
to
Hepatitis
 WORLD
• About 2.3 billion people of the world are infected
with one or more of the hepatitis viruses.

• Viral hepatitis results in around 1.4 million deaths

each year, HBV and HCV are responsible for about
90% of these fatalities, whilst the remaining 10% of
fatalities are caused by other hepatitis viruses.

• Globally, only 1.5 million clinical cases of HAV are

reported annually while the rate of infection is much
higher.
 Cont…
• Approximately one-third of the World’s population
have been infected with HBV.

• Around 5% of this population are chronic carriers

and a quarter of these carriers develop serious liver
diseases such as chronic hepatitis, cirrhosis and
hepatic carcinoma.

• Every year, 7,80,000 HBV-related deaths are

documented around the globe.
-World Journal of Clinical Cases (2018)
 Classification

• Viral Hepatitis
• Bacterial Hepatitis
• Toxic and drug-induced hepatitis
• Alcoholic hepatitis
• Autoimmune hepatitis
 Viral Hepatitis
• Viral hepatitis is the most common type of
hepatitis worldwide.

• The most common causes of viral hepatitis are

the five unrelated hepatotropic viruses
hepatitis A, B, C, D, and E.

• Other viruses can also cause liver

inflammation, including cytomegalovirus,
Epstein-Barr virus etc.
 Bacterial Hepatitis
• Bacterial infection of the liver results in pyogenic
liver abscesses, acute hepatitis, or granulomatous (or
chronic) liver disease.

 Pyogenic abscesses -Escherichia coli and Klebsiella

pneumoniae.

 Acute hepatitis-Neisseria meningitis, Neisseria

gonorrhoea etc.
 Chronic or granulomatous hepatitis -mycobacteria
species, Treponemapallidum and rickettsia species.
 Toxic and drug-induced hepatitis
• Many chemical agents, including medications,
industrial toxins, and herbal and dietary
supplements, can cause hepatitis.

• The spectrum of drug-induced liver injury

varies from acute hepatitis to chronic hepatitis
to acute liver failure.

• Mechanisms of injury includes direct

cell damage, disruption of cell metabolism,
and causing structural changes.
 Alcoholic hepatitis

• Excessive alcohol consumption is a significant cause

of hepatitis and is the most common cause of
cirrhosis.

• Alcoholic hepatitis is within the spectrum of

alcoholic liver disease.

• This ranges in order of severity and reversibility

from alcoholic steatosis (least severe, most
reversible), alcoholic hepatitis, cirrhosis, and liver
cancer (most severe, least reversible).
 Cont…
• Hepatitis usually develops over years-long
exposure to alcohol, occurring in 10 to 20% of
alcoholics.

• The most important risk factors for the

development of alcoholic hepatitis are quantity
and duration of alcohol intake
 Autoimmune hepatitis
• It is a chronic disease caused by an abnormal
immune response against liver cells. Formerly
called lupoid hepatitis.

• It occurs when the body's immune system

attacks liver cells causing the liver to be
inflamed.
• Affected people are often positive for human
leukocyte antigen with circulating
auto-antibodies which help in diagnosis.
 Types of viral hepatitis

• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis E
 Stages of Hepatitis Infection
• The various clinical patterns and pathologic
consequences of different hepatotropic viruses
can be considered under the following
headings:
i) Carrier state
ii) Asymptomatic infection
iii) Acute hepatitis
iv) Chronic hepatitis
v) Fulminant hepatitis (Submassive to massive
necrosis)
 Carrier State

• An asymptomatic individual without

manifesting disease, harbouring infection with
hepatotropic virus and capable of transmitting
it is called carrier state.

• Hepatitis A and E do not produce the carrier

state.
• Hepatitis B is responsible for the largest
number of carriers in the world
 Asymptomatic Infection

These are cases who are detected incidentally

to have infection with one of the hepatitis
viruses as revealed by their,
-raised serum transaminases or
-by detection of the presence of antibodies but
are otherwise asymptomatic
 Acute viral hepatitis
• Viral infection evolving within hours, days to
few weeks(8 weeks). Some patient may be
entirely asymptomatic or only mildly
symptomatic at presentation.

• Acute hepatitis lasts less than 6 months. Acute

hepatitis can resolve on its own, progress to
chronic hepatitis, or (rarely) result in
acute liver failure. .
 Acute Hepatitis

• The most common consequence of all

hepatotropic viruses is acute inflammatory
involvement of the entire liver.

• In general, type A, B, C, D and E run similar

clinical course and show identical pathologic
findings.

• Clinically, acute hepatitis is categorised into 4

phases: incubation period, pre-icteric phase,
Incubation period:
• It varies among different hepatotropic viruses.
The patient remains asymptomatic during
incubation period but the infectivity is highest
during the last days of incubation period.

Pre-icteric phase:
• This phase is marked by prodromal
constitutional symptoms & the earliest
laboratory evidence of hepatocellular injury in
pre-icteric phase is the elevation of serum
transaminases.
Icteric phase:
• This phase is commenced by the onset of
clinical jaundice and the constitutional
symptoms diminish.

• Other features include dark-coloured urine

due to bilirubinuria, clay-coloured stools due
to cholestasis, pruritus as a result of elevated
serum bile acids, loss of weight and abdominal
discomfort due to enlarged, tender liver.
Post-icteric phase:

• The icteric phase lasting for about 1 to 4

weeks is usually followed by clinical and
biochemical recovery in 2 to 12 weeks.

• The recovery phase is more prolonged in

hepatitis B and hepatitis C.
 Chronic Hepatitis
• Chronic hepatitis is defined as continuing or
relapsing hepatic disease for more than 6
months .

• Majority of cases of chronic hepatitis are the

result of infection with hepatotropic viruses—
hepatitis B, hepatitis C and combined hepatitis
B and hepatitis D infection.

• Chronic hepatitis may progress to scarring of

the liver (cirrhosis), liver failure, and
Stages of liver disease
 Fulminant Hepatitis (Submassive to Massive Necrosis)

• Fulminant hepatitis is the most severe form of

acute hepatitis in which there is rapidly
progressive hepatocellular failure.

Two patterns are recognised:

• Submassive necrosis having a less rapid
course extending up to 3 months
• Massive necrosis in which the liver failure is
rapid and fulminant occurring in 2-3 weeks.
Hepatitis A (Infectious hepatitis)

Etiology:
Hepatitis A virus (HAV).
HAV is a RNA virus of Entero virus family.

Incubation period:
15-50 days (average 28 days)
 Mode of transmission

• Feco-oral route (the ingestion of food or liquid

infected by the virus)

• Close personal contact

• Transmission possible with oral-anal contact

during sex
 Pathophysiology
Hepatitis A virus invade the body

Multiplication occurs in intestinal epithelium

Reaches liver by intestinal epithelium

Replication within liver cells

Enters intestine with bile

 Diagnosis
 History taking
 Physical examination
 Detection of antibody:
-Enzyme Linked ImmunosorbantAssay
(ELISA)

 Anti-HAV IgM in acute infection

 Anti-HAV IgG for recovery and immunity to
virus
 Cont..
 Biochemical test: Bilirubin, protein and
alanine aminotransferase
 Stool examination.
 Treatment

• During acute stage, provide adequate bed rest

and nutritious diet to the patient.

• Anorexia can be managed by giving small,

frequent meals and supplemented IV fluids
with glucose
• Most people recover completely
• No medicine or treatment to make it go away.
• Prevention
• Good personal hygiene
• Environmental sanitation
• Administration of immunoglobulin : Give this Hepatitis
A vaccine within two weeks of exposure. Passive
immunity is produced after 6-8 weeks. Immunoglobulin
suppress over the symptoms of this disease.
• Pre-exposure prophylaxis for people age 2 and older
who are traveling to or working in developing countries
should strongly consider the Hepatitis A vaccine.
 Hepatitis A vaccination

Routine vaccination
• 2-dose series HepA
- Havrix 6–12 months apart or Vaqta 6–18
months apart (minimum interval: 6 months) or

• 3-dose series
- HepA-HepB (Twinrix at 0, 1, 6 months
[minimum intervals: 4 weeks between doses 1
and 2, 5 months between doses 2 and 3])
 Cont…
• Post exposure prophylaxis: Give Hepatitis A
vaccine within two weeks of exposure. Active
immunity is produced after 6-8 weeks.
Immunoglobulin suppress over the symptoms of this
disease.

• Pre-exposure prophylaxis for people age 2 and older

who are traveling to or working in developing
countries should strongly consider the Hepatitis A
vaccine.
 Hepatitis B
• Hepatitis B, also known as Serum hepatitis.

• It is a serious disease that infect the liver and

can cause life long infection, cirrhosis, liver
scarring , liver cancer, liver failure and death.

• Etiology: Hepatitis B virus (HBV).

HBV is a double shelled DNA virus of
enterovirus family.
 Cont..

• Incubation period: 48-180 days (average 120

days)

• HBV virus is found in the blood and in lesser

amounts in body fluids like saliva, semen,
vaginal secretions etc. of an infected person.
• Mode of transmission:
• Hepatitis B is mainly transmitted by,
• Unprotected sex with an infected person
• Sharing needles with an infected person
• Tattooing and piercing with tools that were not sterilized
• Sharing personal items such as razors or toothbrushes with an
infected person
• Mothers can inoculate the baby during the birth process
• Accidental needle pricks
• Blood transfusion
• Hemodialysis
 Pathophysiology
Invasion of virus into the body

Multiplication inside the liver cells

Hepatocellular injury

Inflammatory cells infiltrate into the portal tracts

Kupffer cell hyperplasia

Cholestasis
Clinical manifestations
 Cont…
Extrahepatic manifestation:
 Include myalagia, photophobia, arthritis,
angioedema, urticaria, maculopapular
eruption, skin rashes that are immune
mediated due to deposition of immune
complexes in response to the virus.
 Diagnosis
 History taking
 Physical examination
• Serological tests: Enzyme Linked Immunosorbant
Assay (ELISA)

- Hepatitis B surface antigen (HBsAg)present in blood,

indicate acute or chronic state and,
- Antibody to HBsAg (Anti-HBs), detected in serum
during late convalescence, usually indicate recovery /
development of immunity
 Cont…
• Hepatitis B core antigen (HBcAg) found only in liver
cells, not serum.
-Antibody (anti-HBcIgM, marker of acute infection
and anti-HBcIgG, marker of past or chronic
infection).

• Hepatitis B e antigen (HBeAg) signifies higher

infectivity and
-Antibody to HBeAg (anti-HBe) are independent
protein circulating in the blood & signifies reduced
infectivity.
 Biochemical test:
• Total and direct bilirubin
• Aspartate transaminase, alanine transaminase
and alkaline phosphatase
• Prothrombin time
• Total protein, albumin, serum globulin
• Complete blood count
• Coagulation studies
Liver function test Normal Range
Liver Function Tests (LFT)
Bilirubin 0.1 to 1.0 mg
Total < 0.2 mg
Conjugated

Alkaline phosphatase 25-112 iu/L

Aspartate transaminase
5-31 iu/L
(AST/SGOT)

Alanine transaminase
5-35 iu/L
(ALT/SGPT)

Albumin 3.5-5.0 g/dL

Prothrombin time (PT) 12-16 s

55
 Treatment

• The aim of the treatment is to stop viral

replication, reduce liver damage, and improve
the quality of life. Eradication of the virus is
rare.
 Cont…
• Following measures can be implemented,
 Physical rest
 Psychological rest

 Adequate nutrition- Low fat and lean protein.

Proteins are restricted if symptoms indicate
that the liver’s ability to metabolize protein
by-product is impaired.
Drug therapy:
• Alpha-interferone IV TDS to decrease
inflammation
• Antiviral drugs:
-Lamivudine (Epivir HBV) and
-Adefovir dipivoxil (Hepsera) orally
• Immunomodulating drugs:
-Oral ribavirin ( Virazol )
• Antiemetics to control vomiting
 Immunization

3-dose series (Adult)

• Engerix B: 1 mL (20 mcg) IM at 0, 1, and 6
months
• Recombivax HB: 1 mL (10 mcg) IM at 0, 1,
and 6 months
• Heplisav-B: Can be used as a substitute in a 3-
dose series with a different hepatitis B vaccine
 Cont…
2-dose series
• Heplisav-B (aged ≥18 years): 0.5 mL IM at 0 and 1
month

Adults receiving dialysis or other immuno-

compromising conditions
• Recombivax HB (40 mcg/mL): 40 mcg IM at 0, 1,
and 6 months, OR
• Engerix-B (20 mcg/mL): 40 mcg IM at 0, 1, and 6
months
• Active immunizations : the immunizations for adult
> 20 years three doses (0, 30,180 days) of 1ml
vaccine IM with no booster is effective to prevent
hepatitis B infection

• Passive immunization : for immediate protection ,

HBIg (hepatitis B immunoglobulin ) is used for those
acutely exposed to HBs positive blood.

• HBIg should be given as soon as possible after

accidental inoculation ( ideally within 24 hours of
exposure) shouldn’t be given later than 14 days
Thank You
 Hepatitis C
• Also known as non A, non B Hepatitis
previously.

• Etiology: Hepatitis C virus (HCV). HCV is a

RNA virus of enterovirus family.

• Incubation period: 14-180 days

• Mode of transmission: Same as Hepatitis B
 Pathophysiology
• HCV is a virus that is carried in the blood
stream to the liver.

• It can then affect and damage the liver.

• This virus can also affect other parts of the

body such as digestive, nervous and immune
system.
 Clinical manifestations
Acute phase ( 6 months)

• Usually symptoms are not present. If

symptoms do occur, they develop about 7-8
weeks after being exposed to the virus and
may include feeling sick, vomiting and feeling
generally well.

• Some people may develop jaundice.

 Chronic phase
• It lasts for longer than 6 months

People may develop the following symptoms:

• Mild or no symptoms
• Feeling sick, loss of appetite, intolerance of alcohol,
pain over the liver, jaundice and depression
• Most common, extreme tiredness, poor
concentration and memory problems, muscle and
joint pain
• 1/3rd of people may develop cirrhosis over a period
of about 20-30 years
 Diagnosis
• History taking
• Physical examination
• Detection of antibody:
- Enzyme Linked Immunosorbant Assay
(ELISA)
• Anti-HCV antibody in acute infection
• Does not provide immunity to virus
 Cont…
• Polymerase chain reaction (PCR) to detect
the virus.
• Liver function tests
• Ultrasound scan
• Liver biopsy
 Treatment
• The main aim of treatment is to clear the HCV
virus from the body and prevent severe
damage leading to cirrhosis.

• The treatment consists of combination of two

different medicines
- PEGylated interferon (peginterferone)
- Ribavirin , fights virus

• Liver transplant- for advanced cirrhosis

 Prevention

• Avoid sharing any injecting equipment

• Practice safe sex
• Avoid sharing personal items that may be
contaminated with blood, eg. Razor
• Donor screening for blood and tissue products
• No vaccine exists for HCV.
 Hepatitis D
• Also known as delta virus. Unlike the other
forms, hepatitis D cannot be contracted on its
own. It can be contracted only if a person is
already infected with hepatitis B.

• Etiology: Hepatitis D virus (HDV). HDV is a

RNA virus of enterovirus family.
• Mode of transmission:
Blood or body fluids as with HBV.
• Incubation period: 14-56 days
 Clinical manifestations

• The symptoms of hepatitis B and hepatitis D

are similar. The common symptoms include:
- Jaundice, joint pain, abdominal pain, vomiting,
loss of appetite, dark urine, fatigue

• Hepatitis D can also cause the symptoms of

hepatitis B to worsen or appear in those who
have been infected but have not yet developed
symptoms.
 Diagnosis

• History taking
• Physical examination
• Detection of antibody:
- Enzyme Linked Immunosorbant Assay (ELISA)
• Anti-HDV antibody in acute infection
• Does not provide immunity to virus
• Polymerase chain reaction (PCR) to detect
the virus.
• Liver function tests
 Treatment

• Currently there are no known treatments for

acute or chronic hepatitis D.

• Chronic HDV is treated with alpha interferone

in practice.

• Antiviral medications do not seem to be very

effective in treating hepatitis D.
 Prevention
• Preventing HBV also prevents HDV.

• It is recommended that all persons be vaccinated for

Hep. B.
• Standard precautions for all the patients in the health
care setting.

• Avoid contact with infected blood, contaminated

needles and an infected person’s personal items.
 Hepatitis E
• Etiology: Hepatitis E virus (HEV).
HEV is a RNA virus of enterovirus family.
• Incubation period:15-60 days

• It is usually a self-limiting, and resolves within

4-6 weeks.
• HEV is more severe in pregnant women,
especially in the third trimester.
 Mode of transmission

• Feco-oral route due to fecal contamination of

drinking water.
• Eating contaminated raw shellfish
• Ingestion of products derived from infected
animals.
• Food handlers infected with the virus
• Vertical transmission from pregnant women to
fetus
 Clinical manifestations

• Symptoms are similar to Hepatitis A infection,

which includes,

- Jaundice, anorexia, hepatomegaly, abdominal

pain and tenderness, nausea and vomiting and
fever.
 Diagnosis
• History taking
• Physical examination
• Detection of antibody:
- Enzyme Linked Immunosorbant Assay (ELISA)
• Anti-HEV antibody in acute infection
• Once infected with HEV, the person is immune to
virus
• Reverse transcriptase polymerase chain
reaction (RT-PCR) to detect the virus.
• Liver function tests
 Treatment

• Treatment with immunoglobulin immediately

after exposure within two weeks of exposure.

• Usually self-limiting, no treatment required.

• Hospitalization is required in case of

fulminant hepatitis and for infected pregnant
women.
• Avoid alcohol
• Symptomatic treatment of flu-like illness
• Prevention
• Hepatitis E vaccine is usually available for
people 2 years or older.
• Maintaining safe water supply
• Establishing proper disposal systems to
eliminate sanitary waste.
Nursing Management
 Nursing assessment

 Baseline history and examination

 Respiratory status
 Skin Integrity
 Nutritional status
 Fluid and electrolyte level
 Bowel and bladder pattern
 Knowledge Level
 Nursing Diagnosis

• Imbalance nutrition less than body requirement

related to anorexia, nausea or vomiting
• Pain related to inflammation and enlargement of
liver
• Ineffective breathing pattern related to intra-
abdominal fluid collection/ ascites.
• Risk for impaired skin integrity related to itching
secondary to bilirubin pigment deposit in skin
• Risk for fluid volume deficit related to excessive
loss through vomiting/ third space shift/ GI
bleeding
 Specific nursing intervention
• Universal precautions such as hand washing,
wearing mask, gloves, gown etc. must be
maintained .
• Monitor for signs of infection
• Pulmonary therapy
• Provide a high calorie, high protein ( unless
contraindicated in fulminant hepatic
condition,) low fat diet
• Administer antiemetic drugs
• Encourage patient to have adequate rest
• Monitor intake /output compare with periodic
weight. Note enteric loss , abdominal girth as
indicated or monitor gastric secretion, stool for
sign of bleeding
• Give analgesics as ordered to control pain
• Use small gauze needle for injection and apply
direct pressure over puncture sitr to avoid
bleed
• Teach the patient to avoid alcohol and drugs
without prescription.
 Pre-exposure evaluation
• Pre-exposure evaluation for health care
personnel previously vaccinated with
complete, ≥3-dose HepB vaccine series who
have not had post-vaccination serologic
testing.
Post exposure prophylaxis
• After exposure to hepatitis B virus (HBV),
appropriate and timely prophylaxis can
prevent HBV infection and subsequent
development of chronic infection or liver
disease.
Contd....
• Recommended management of persons who
are exposed to HBV through a distinct,
identifiable exposure to blood or body fluids
that contain blood, in occupational and
nonoccupational settings :
 Clean wounds with soap and water
 Flush mucous membranes with water
Contd...
 No evidence of benefit for:
-Application of antiseptics or disinfectants

- Squeezing (“milking”) puncture sites.

-Avoid use of bleach and other agents

HBV Exposures in Occupational
Setting
Concentration of HBV in Body Fluids
 Recommended Postexposure
Management: PEP for Exposure to HBV
HCP status Post exposure test Post exposure prophyaxis Post
vaccination
serologic
testing

Source HCP testing HBIG Vaccination

patient (Anti-HBs)
(HBsAg)

Documented No action needed

responder after
complete series

Response Positive/ < 10 mIU/ml HBIG - 1 Initiate Yes

unknown after unknown dose revaccination
complete series
Negetive < 10 mIU/ml - single HepB Yes
vaccine dose
Any result ≥10 mIU/mL - - -
Contd.....
HCP status Post exposure test Post exposure Post
prophyaxis vaccination
serologic
testing
Source HCP HBIG Vaccination
patient testing
(HBsAg) (Anti-HBs)
Positive / <10 HBIG x2 - -
Documented unknown mIU/mL separated by
nonresponde 1 month
r after two Negetive No action needed
complete
series
 Contd......
HCP status Post exposure test Post exposure Post
prophyaxis vaccination
serologic
testing

Source HCP HBIG Vaccination

patient testing
(HBsAg) (Anti-HBs)

Unvaccinated/ Positive / - HBIG- 1 Complete yes

incompletely unknown vaccination
vaccinated or
vaccine Negetive - none Complete yes
refusers vaccination
 HBV Exposures
in
Non Occupational Setting
 PEP for Non occupational Exposure to
HBV
Exposure Management
Previously In the process of Unvaccinated
vaccinated person being vaccinated person
but not completed
the vaccine series

HBsAg-positive a single dose of HBIG and HepB vaccine

source HepB vaccine complete the HepB series and HBIG
vaccine series (it is
not necessary to
restart the HepB
vaccine series)
Contd......
Exposure Management
Previously In the process of Unvaccinated
vaccinated person being vaccinated person
but not completed
the vaccine series

HBsAg status No management complete the HepB Hep B vaccine

unknown for vaccine series (it is series
source not necessary to
restart the HepB
vaccine series)
 PEP for Perinatal Exposure

• Immunoprophylaxis for infants born to HBV-

infected mothers should receive hepatitis B
vaccine and hepatitis B immune globulin
within 12 hours of birth. (80-95% effective)

• Routine vaccination of all infants with the

hepatitis B vaccine series, with the first dose
administered within 24 hours of birth
 Recommended Postexposure
Management: PEP for exposure to HAV
• Passive post exposure immunization with
hepatitis A immune globulin (HAIG) is an
alternative to active immunization with HAV
vaccine.

• Its effectiveness is highest when it is given

within 48 hours of exposure, but it may be
helpful when given as far as 2 weeks into the
incubation period.
Contd...
• Postexposure prophylaxis with HAIG is
appropriate for household and intimate
contacts of patients with HAV.

• It is also recommended for contacts at daycare

centers and institutions. The typical dosing of
HAIG is 0.02 mL/kg IM as a single dose.
Contd...
• Postexposure prophylaxis is not recommended
for the casual contacts of patients, such as
classmates or coworkers.

• For travelers who anticipate spending less than

3 months in an HAV-endemic region, the dose
is 0.02 mL/kg IM.
Contd...
• Travelers who are planning to spend more than
3 months in a region where HAV is endemic
should receive 0.06 mL/kg IM every 4-6
month.
Any queries ???
 References
• Williams, L., S., & Hopper, P., D., (2015), Understanding medical
surgical nursing, 5th edition, Jaypee brothers, Pp. 780-785, 1034
• Daniels R. , Nicoll L., ,(2012), Contemporary Medical-surgical
nursing, Second edition, DELMAR. Pp. 1415- 1421.
• Sharma S.K. &Madhavi S.,(2018), Brunner &Suddarth’s
Medical-surgical nursing, South Asian edition, Volume 2. Wolters
Kluwer.
• Harsh Mohan, (2010), Textbook of pathology, 6 th edition, Jaypee
brothers. Pp-605-614.
• Kumar, Abbas, & Aster,(2018), Robbins basic pathology, 9 th
edition, Saunders Elsevier.
• Sharma M., Poudel K., & Gautam R., (2017), Essential Textbook
of Medical Surgical Nursing, second edition, Samiksha Book Pvt.
Ltd. Pp. 120-124
Contd..
• Retrived from
https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm
on 19 june, 2021
• Retrived from
https://www.who.int/occupational_health/activities/5pepgui
d.pdf on 19 june, 2021
• Retrived from
https://emedicine.medscape.com/article/775507-
treatment#d15 on 19 june, 2021
Thank You