PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
NAME OF THE CANDIDATE AND ADDRESS
Mr. ELDHOSE PAUL
FIRST YEAR M.Sc (NURSING)
EAST WEST COLLEGE OF NURSING
MAGADI MAIN ROAD ,
BANGALORE - 560091
NAME OF THE INSTITUTION
EAST WEST COLLEGE OF NURSING
MAGADI MAIN ROAD, BANGALORE-560091
COURSE OF STUDY AND SUBJECT
First Year M.Sc (Nursing)
Medical Surgical Nursing
DATE OF ADMISSION TO COURSE
TITLE OF THE TOPIC
“Slide show on protocol of managing patients with Guillain Barre Syndrome”
6. BRIEF RESUME OF THE INTENDED WORK
“Body: A thing of shreds and patches, borrowed unequally from good and bad ancestors and a misfit from the start.”- Ralph Waldo Emerson
Health is the general condition of a person in all aspects. It is also a level of functional and/or metabolic efficiency of an organism, often implicitly human. At the time of the creation of the World Health Organization (WHO), in 1948, health was defined as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity"
We have nerves that live outside the central nervous system (the brain and spinal cord), and deal with our body's senses and movements. These are called our peripheral nerves. Guillain-Barre syndrome is a rare but serious autoimmune disorder affecting the peripheral nervous system, usually triggered by an acute infectious process5.
The disorder was first described by the French physician Jean Landry in 1859. In 1916, Georges Guillain, Jean Alexandre Barre, and André Strohl diagnosed two soldiers with the illness and discovered the key diagnostic abnormality of increased spinal fluid protein production, but normal cell count.GBS is also known as acute inflammatory demyelinating polyneuropathy, acute idiopathic polyradiculoneuritis, acute idiopathic polyneuritis, French Polio, Landry's ascending paralysis and Landry Guillain Barré syndrome18.
Overall annual incidence of GBS varies between 1/91,000 and 1/55,000. In Europe and North America, AIDP is the most frequent form of GBS (accounting for around 90% of cases) and thus the term GBS in general is synonymous with AIDP in Western countries. The axonal forms account for only 3-5% of cases in Western countries but are much more frequent (30%-50% of GBS cases) in Asia and Latin America. Incidence rate of Guillain-Barre Syndrome: approx 1 in 100,000 or 0.00% or 2,720 people in USA. Incidence extrapolations for USA for Guillain-Barre Syndrome: 2,720 per year, 226 per month, 52 per week, 7 per day.24
Guillain-Barré is one of the leading causes of (acute) non-trauma-induced paralysis in the world5.What exactly causes the condition is unclear and there is no way to pinpoint who may be most at risk. However, in most cases of Guillain-Barre syndrome the person had a virus or bacterial infection in the last four weeks. In about2⁄3 of patients, the syndrome begins 5 days to 3 wk after a bacterial infectious disorder, surgery, or vaccination21. Infection is the trigger in > 50% of patients; common pathogens include Campylobacter jejuni, enteric viruses, herpes viruses (including cytomegalovirus and Epstein-Barr virus), and Mycoplasma sp. A cluster of cases followed the swine flu vaccination program in 1975.21
It makes the body’s own immune system attack the nerves, causing widespread inflammation that leads to a tingly, numbing sensation in the arms and legs. This can eventually result in a short-term loss of feeling and movement (temporary paralysis). It is frequently severe and usually exhibits as an ascending paralysis noted by weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes. It is slightly more common in men than women, and can affect people of any age, even children, so it is also called as an autoimmune disorder23.
Guillain-Barre syndrome is a medical emergency and 100% of the case requires hospitalization, though it is a self remitting disease and affects motor neurons, thus paralysing the muscles. The most dangerous aspect is if it involves phrenic nerve and diaphragm is paralyzed, respiration may stop and patient may not be able to survive. However, death may occur if severe pulmonary complications and autonomic nervous system problems (wide fluctuations in blood pressure, orthostatic hypotension, and cardiac arrhythmias) are present21.
Supportive care with monitoring of all vital functions is the cornerstone of successful management in the acute patient. Early intubation should be considered in any patient with a vital capacity <20 ml/kg, a negative inspiratory force within 24 hours, rapid progression of disorder, or autonomic instability. Once the patient is stabilized, treatment of the underlying condition should be initiated as soon as possible. Either high-dose intravenous immunoglobulins (IVIg) at 400 mg/kg for 5 days or plasmapheresis can be administered, as they are equally effective and a combination of the two is not significantly better than either alone. Therapy is no longer effective two weeks after the first motor symptoms appear, so treatment should be instituted as soon as possible. Following the acute phase, the patient may also need rehabilitation to regain lost functions. This treatment will focus on improving activities of daily living functions such as brushing teeth, washing, and getting dressed. A nurse will identify the patient needs and make use of services from occupational therapist. Physiotherapist, speech and language therapist..etc18.
Most people will make a full recovery within a few weeks or months, with no further trouble. Some cases take longer to recover from and there is a possibility of permanent nerve damage.18
6.2NEED FOR THE STUDY.
Guillain-Barre syndromeis a rare disorder in which the body's immune system attacks part of the peripheral nervous system. Symptoms of this disorder include muscle weakness, numbness, and tingling sensations, which can increase in intensity until the muscles cannot be used at all. So caring of GBS requires intensive care management and mechanical ventilation support. Any minute negligence from the part of a staff nurse while caring may result in death of the patient, therefore nurses will be extra careful in identifying, management and rehabilitation of GBS patients. Most patients recover completely, after getting a prompt care.16
A preliminary report by the CDC's Emerging Infections Programs (EIP) calculates the rate of GBS observed in patients who previously received the 2009 H1N1 influenza vaccination is an excess of 0.8 per million cases, which is on par with the rate seen with the seasonal trivalent influenza vaccine. 20
This syndrome is fatal in < 2%. Most patients improve considerably over a period of months, but about 30% of adults and even more children have some residual weakness at 3 yr. Patients with residual defects may require retraining, orthopedic appliances, or surgery16. The incidence of GBS during pregnancy is 1.7 cases per 100,000 of the population. The mother will generally improve with treatment but death of the fetus is a risk. The risk of Guillain–Barré syndrome increases after delivery, particularly during the first two weeks postpartum.8
Guillain Barre Syndrome remains one of the leading cause for acute flaccid paralysis in India affects 10,650 cases. Although some people can take months and even years to recover, most cases of Guillain-Barre syndrome follow this general timeline: the first symptoms, the condition tends to progressively worsen for about two weeks. Symptoms reach a plateau and remain steady for two to four weeks. Recovery begins, usually lasting six to 12 months22.
The Process Standards define the "action and behaviors of nurses giving care and what constitutes that care. The Process Standards include job descriptions, the job performance evaluation tool, procedures, and protocols. Central to the standards program are the protocols, which guide the majority of nursing actions and are a key component of the patients' plan of care. The protocols truly provide what the staff nurse needs. The protocols set the standard for care, provide a wonderful reference and teaching tool for the nurse, and serve as the nursing orders to define the plan of care for the patient.11
Protocols are the foundation for nursing actions. They define in "specific terms the management for Guillain Barre Syndrome patient care problems". Protocols, their consistency, appropriateness and implementation are essential tools in the delivery of high quality care. 24
In India the statistics shown that only few hospitals are following the quality based protocol care in the intensive care units for managing patients with Guillain Barre Syndrome. This shows a lag in standardized patient care in many of the hospitals.
Various studies states that negligence from the part of nurses may worsen the condition or end up in death of patients with Guillain Barre Syndrome. A nurse who cares Guillain Barre Syndrome patients should well aware of the disease condition, its progression and most importantly the standardized care. Therefore providing quality care requires an approved protocol for managing the Guillain Barre Syndrome patients. If we teach the protocol based nursing care to the B.sc Nursing students will benefit better outcome in the quality of patient care.
6.3 CONCEPTUAL FRAME WORK
To describe the relationship of concepts in the study, open system model by J.W.Kenny’s (1991) is used. Open system model serves as a model for reviewing people as interacting with the environment. Theoretical framework provides a certain frame work of reference for clinical practice, research and education.
“Open systems model is a set of related definitions, assumptions and prepositions which deals with reality as an integrated hierarchy.” systems model focuses in each system as a whole, but pays particular attention to the interaction of its part or subsystems. A system is a group of elements that interact with one another in order to achieve a goal.
The following are the major concepts of the theory
Input: Input is the matter, energy and transformation that enter the system. In the present study, the input is the characteristics of the student nurse like gender, age, religion, area of residence, previous information acquired regarding the management of Guillain Barre Syndrome, 4th year B.Sc Nursing students, who passed all third year subjects.
Objectives: This contributes directly to the knowledge they possess on protocol in managing patients with Guillain Barre Syndrome care. The knowledge was assessed and measured using questionnaire. The questionnaire was constructed based on disease protocol and condition. It includes anatomy and physiology of peripheral nervous system, meaning, types, signs and symptoms, diagnosis, treatment, nursing management and complications for Guillain Barre Syndrome care.
Throughput: Throughput is the use of biologic, psycho logic and socio-cultural sub systems to transform the inputs. Throughput was the processing of information of Guillain Barre Syndrome care through slideshow assisted teaching.
Output: Output is the return of matter, energy and information to the environment in the form of both physical and psychosocial behavior. The expected outcome was obtained by assessing the knowledge and skills through close-ended questionnaire. The output was considered in times of change in post test knowledge scores obtained through close-ended questionnaire
Feedback: Differences in pre and post test scores were observed from the knowledge and practice scores of the samples. In the present study, the feedback was considered as a process of maintaining the effectiveness of slideshow assisted teaching. It was assessed by comparing the pre and post test scores, through ‘t’ test. The effectiveness of the slideshow assisted teaching was also tested between the obtained scores of the samples with their demographic variables through chi-square and the effectiveness of slideshow assisted teaching related to the association of knowledge on practice was tested through the ‘r’ value.
6.4 REVIEW OF LITERATURE
Review of literature is a critical summary of research on a topic of interest generally prepared to put a research problem in paper content to identify gaps and weakness on previous studies to justify a new investigation.
The review of literature for the present study has been divided into the following sections
A study was conducted (in Lombardy, Italy to assess the annual incidence of typical Guillain Barre syndrome (GBS) and its main variants (atypical GBS) in a well-defined population from a large area. Patients with GBS diagnosed according to National Institute of Neurological and Communicative Disorders and Stroke criteria in the 2-year period 1995 to 1996 among patients for 2 years after onset of GBS. A total of 120 patients were found, corresponding to a crude annual incidence rate of 1.36/100,000 population (95% CI, 1.13 to 1.63). A total of 7 (5.8%) patients, all but one with axonal or mixed EMG pattern, died acutely within 30 days from the onset of the disease. Acute mortality was due to respiratory involvement and intensive care unit complications. In multivariate analysis, a worse 2-year outcome (Hughes score ≥2) was related to a higher Hughes grade at nadir, axonal or mixed EMG, age ≥50 years, and absence of respiratory infections preceding GBS. The persistence of disability 2 years after the acute phase was related to axonal involvement and a worse status at nadir. After adjustment to US population, the incidence rates for GBS from different countries showed no significant differences. Both acute mortality and long-term disability in GBS seem to be related to an axonal involvement and a Hughes grade ≥2 at nadir25.
A study was conducted by Kuwabara S to determine the epidemiology, pathophysiology and management of Guillain-Barré syndrome .GBS occurs throughout the world with a median annual incidence of 1.3 cases per population of 100 000, with men being more frequently affected than women. GBS is considered to be an autoimmune disease triggered by a preceding bacterial or viral infection. Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus and Mycoplasma pneumoniae are commonly identified antecedent pathogens. In the acute motor axonal neuropathy (AMAN) form of GBS, the infecting organisms probably share homologous epitopes to a component of the peripheral nerves and, therefore, the immune responses cross-react with the nerves causing axonal degeneration; the target molecules in AMAN are likely to be gangliosides GM1, GM1b, GD1a and GalNAc-GD1a expressed on the motor axolemma. In the acute inflammatory demyelinating polyneuropathy (AIDP) form, immune system reactions against target epitopes in Schwann cells or myelin result in demyelination; however, the exact target molecules in the case of AIDP have not yet been identified. AIDP is by far the most common form of GBS in Europe and North America, whereas AMAN occurs more frequently in east Asia. The prognosis of GBS is generally favorable, but it is a serious disease with a mortality of approximately 10% and approximately 20% of patients are left with severe disability. Treatment of GBS is subdivided into: (i) the management of severely paralyzed patients with intensive care and ventilatory support; and (ii) specific immune modulating treatments that shorten the progressive course of GBS, presumably by limiting nerve damage. High-dose intravenous immunoglobulin therapy and plasma exchange aid more rapid resolution of the disease. Corticosteroids alone do not alter the outcome of GBS20.
Studies on signs and symptoms of Guillain Barre Syndrome
A study was conducted to obtain detailed information about pain in GBS and its clinical variants. This was a prospective cohort study in 156 patients with GBS .We assessed the location, type, and intensity of pain using questionnaires at standard time points during a 1-year follow-up. Pain data were compared to other clinical features and serology. Pain was reported in the 2 weeks preceding weakness in 36% of patients, 66% reported pain in the acute phase (first 3 weeks after inclusion), and 38% reported pain after 1 year. In the majority of patients, the intensity of pain was moderate to severe. Longitudinal analysis showed high mean pain intensity scores during the entire follow-up. Pain occurred in the whole spectrum of GBS. The mean pain intensity was predominantly high in patients with GBS patients with sensory disturbances, and severely affected patients. Only during later stages of disease, severity of weakness and disability were significantly correlated with intensity of pain. Pain is a common and often severe symptom in the whole spectrum of GBS (including MFS, mildly affected, and pure motor patients). As it frequently occurs as the first symptom, but may even last for at least 1 year, pain in GBS requires full attention. It is likely that sensory nerve fiber involvement results in more severe pain24.
A study was conducted to determine the morbidity of Guillain-Barré syndrome admitted to the intensive care unit. To understand the spectrum of morbidity associated with ICU care, the authors studied 114 patients with GBS. Major morbidity occurred in 60% of patients. Complications were uncommon if ICU stay was less than 3 weeks. Respiratory complications such as pneumonia and tracheobronchitis occurred in half of the patients and were linked to mechanical ventilation. Systemic infection occurred in one-fifth of patients and was more frequent with increasing duration of ICU admission. Direct complications of treatment and invasive procedures occurred infrequently. Life-threatening complications such as gastrointestinal bleeding and pulmonary embolism were very uncommon. Pulmonary morbidity predominates in patients with severe GBS admitted to the ICU. Attention to management of mechanical ventilation and weaning is important to minimize this complication of GBS. Other causes of morbidity in a tertiary center ICU are uncommon25.
Studies on diagnosis of Guillain Barre Syndrome
A study was conducted to determine the data from patients admitted to theintensive care unit with recent diagnosis of Guillain-Barré syndrome and intubation for respiratory failure McClelland at Mayo Clinic, Rochester, Minn. The database of patientswith Guillain-Barré syndrome admitted to the intensivecare units during the past 2 decades was reviewed. Emergencyintubation was defined as need for ventilation in a patientwith sudden dyspnea, cyanosis, or respiratory arrest. Six patients were intubated for acute respiratorydistress and 1 patient for respiratory arrest. Thirty-six patients were intubated electively. Prolonged weaning was twice as commonin the emergent group as in the elective group; a larger samplesize might have demonstrated statistical significance. One patientwith respiratory arrest developed marked anoxic encephalopathy;in all others, no differences were found in mortality, pulmonarymorbidity, or duration of ventilatory assistance. None of theemergency intubations occurred in the last 15 years of the study. Emergency intubation in Guillain-Barrésyndrome is uncommon but, when associated with respiratory arrest, can lead to anoxic encephalopathy. Duration of ventilator useand pulmonary morbidity are not increased in these patients25.
Studies on treatment and management of Guillain Barre Syndrome
A study was conducted to determine management and outcome of severe Guillain-Barré syndrome among 79 patients with Guillain-Barré syndrome admitted to a neurological intensive therapy unit (ITU) between 1985 and 1992 were studied retrospectively. The mean age was 49.8 years (range 16–86) and the time between the first neurological symptom and admission to ITU was 10.2 days (0–62). Admission was precipitated by a combination of respiratory failure requiring ventilatory support (73.4%), bulbar weakness (57.0%), autonomic features (11.4) and general medical factors (10.1%). Specific treatments included plasma exchange (65.8%), intravenous immunoglobulin (13.9%) and methylprednisolone or placebo (12.7%). Significant complications included lower respiratory tract infections (45.6%), hyponatraemia (25.3%), dysautonomia (19.0%), urinary tract infection (12.7%) and cognitive disturbances (8.9%). Four patients (5.1 %) died during the acute illness.. The low mortality in this series of acutely ill and severely disabled patients suggests that specialized intensive therapy units continue to have an important role in the management of acutely ill patients with Guillain-Barre syndrome25.
A study was conducted to determine the Limited Relapse in Guillain-Barré Syndrome After Plasma Exchange. 10 of 94 consecutive patients with acute Guillain-Barrésyndrome treated with plasma exchange relapsed after initialimprovement. Deterioration occurred five to 42 days after thefirst series of exchanges, was usually mild, and in eight re-treatedpatients, responded to a second series of plasma exchanges.None developed chronic inflammatory demyelinating polyneuropathy.The initial exchanges began three to 22 days (mean, 11 days)and ended 14 to 27 days (mean, 19 days) after the onset of illness.The biphasic course in these patients with limited relapsessuggests that plasma exchange removes a circulating factor thatcontinues to be active if treatment is stopped too early. Re-treatment with a second, and sometimes a third, series of plasma exchangesmay be effective22.
Studies on critical care protocol for Guillain Barre Syndrome
A study to assess the protocol driven care in the intensive care unit: a tool for quality to describe their experiences with developing and implementing an extubation protocol, illustrating the successes of using a MDT for this task. Their analysis consisted of 47 consecutive patients extubated according to their new protocol, and outcomes were compared with those of historical control individuals. The primary outcome (staff satisfaction and acceptance during the protocol development and implementation phases) was reported as favorable and positive. Unfortunately, that study neither describes how these satisfaction data were measured nor how the validity of such results was established. Secondary outcomes (mechanical ventilator days [mean 6.7 days], duration of ICU stay [mean 9.3 days], and reintubation rate [10.6%]) were similar to those in the historical control cohort. The study’s small sample size limited its ability to show a difference in outcomes. In addition, the initiation of spontaneous breathing trials required a physician order, a step that promotes inefficiency and prolongs ventilator times19.
Studies on training of health personal with protocol for Guillain Barre Syndrome
A study was conducted to assess the specialized Nursing care to the patient with acute neurologic injury in a general critical care unit. The team presented a timeline of endeavors starting with group inception in January 2005 through August 2007. Team members were identified, and constructed and revised documents with current monitoring equipment were displayed. One patient’s story of success was highlighted. Three years after establishing the core neurology nurses, objective data were reviewed to determine if changes in practice resulted in improved outcomes. All patients admitted to CCC with the diagnosis of TBI, closed head injury, or hemorrhagic stroke from 2002 to 2007 were included in the data collection. Data reviewed included mortality rates, length of stay, and disposition of patient. Type of treatment, medications, or attending physician was not evaluated. Patients were divided into 2 groups: patients with ANI admitted from 2002 to 2004 were in group 1 (before the establishment of the core neurology nurses) and patients admitted from 2005 to 2007 were in group 2 (after establishment of the core neurology nurses). Mean age of patients was 61.8 years for group 1 and 62.6 years for group 2. Preliminary analysis reveals that outcomes in group 2 patients had improved in the 3 categories. Length of stay and mortality rates decreased, and patients being discharged home with home care or self-care had increased. Statistically significant differences in scores were not determined. Analysis of data continues. Retention rates of nurses in the core neurology nurse group are high. Of the original nurses desiring to be in the group, only 2 failed to complete all educational components. Three nurses left the group when they left the institution. Nurses originally desiring to be in the core neurology nurses (27 of 32, or 84.4%) are still members. Completion of 2 supplementary neurology educational series added 9 nurses to the group, currently totaling 36 nurses21..
6.5 STATEMENT OF THE PROBLEM
“A study to evaluate the effectiveness of slide show on protocol of managing patients with Guillain Barre Syndrome among 4th year B.Sc Nursing students in selected colleges at Bangalore”.
6.6 OBJECTIVES OF THE STUDY
To assess the pre-test knowledge of subjects regarding protocol of managing patients with Guillain Barre Syndrome.
To assess the post-test knowledge of the participants regarding protocol of managing patients with Guillain Barre Syndrome.
To compare pre-test and post-test knowledge scores on protocol of managing patients with Guillain Barre Syndrome.
To find out the association between the mean knowledge score with selected demographic variables of the participants.
6.7 OPERATIONAL DEFINITIONS
Effectiveness: Refers to significant increase in post test knowledge score of the participants on knowledge in managing patients with Guillain Barre Syndrome with administering slide show assisted teaching program by following protocol.
Slideshow: It is a teaching strategy by using LCD as an audiovisual aid in providing information on protocol for managing patients with Guillain Barre Syndrome
Guillain-Barre Syndrome: Guillain-Barre syndrome is a serious disorder that occurs when the body's defense (immune) system mistakenly attacks part of the nervous system. This leads to nerve inflammation that causes muscle weakness.
B.Sc Nursing 4th year students: Refers to the students who passed all third year subjects
Protocol: written directions for assessment and management of Guillain Barre Syndrome that was unanimously approved by the The American Nurses Association
H1: There will be a significant difference between pre test and post test knowledge scores on protocol for managing patients with Guillain Barre Syndrome among the study participants.
H2: There will be a significant association between the mean knowledge score with selected demographic variables of the participants.
B.Sc Nursing 4th year students may not have an idea about protocol for managing patients with Guillain Barre Syndrome
All students are given equal opportunity to participate
7. MATERIALS AND METHODS:
7.1 RESEARCH APPROACH:
Research approach used in this study is the Survey approach
7.2 RESEARCH DESIGN:
The research design adopted for the present study is quasi pre-experimental design: One group pre test and post test design.
In the classroom at selected college, Bangalore.
Population considered in this study is B.Sc Nursing 4th year students
Sample for this study is 4th year B.Sc Nursing students who fulfilled the inclusion criteria.
7.6 SAMPLE SIZE:
The proposed sample size for the present study is 50
7.7 SAMPLING TECHNIQUE:
The sampling technique adopted for the study is simple random sampling technique.
B.Sc Nursing students who cleared all 3rd year subjects.
Students who are willing to participate in the study.
B.Sc Nursing 4th year students who are available at the period of study.
B.sc nursing students other than outgoing B.Sc Nursing 4th year batch.
Students those who underwent special training.
Those who exposed to same type of teaching program
Slide show on protocol in managing patients with Guillain Barre Syndrome.
Knowledge of B.Sc Nursing 4th year students
Age, sex, race, area of residence, type of family, Socio-economic status.religion
7.10 TOOLS FOR DATA COLLECTION:
Tool 1: Socio demographic data prepared by the investigator.
Tool 2: Structured knowledge questionnaire on protocol for managing patients with Guillain Barre Syndrome among 4th year B.Sc Nursing students will be prepared by the investigator.
7.11 METHOD OF DATA COLLECTION:
Data will collect through self administer questionnaire
7.12 METHOD OF DATA ANALYSIS:
The collected data will be analyzed by using the appropriate descriptive and inferential statistics method
7.13 DURATIONOF DATA COLLECTION
Duration of data collection will be 4 weeks.
7.14 PROJECTED OUTCOME:
Slideshow assisted teaching program will help the B.Sc Nursing 4th year students to develop basic knowledge on protocol for managing patients with Guillain Barre Syndrome. The students should be able to develop knowledge regarding the incidence, signs and symptoms, diagnosis, treatment and nursing management
7.15 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes, the study requires administration of slideshow assisted teaching program on protocol for managing patients with Guillain Barre Syndrome among B.Sc Nursing 4th year students in selected colleges at Bangalore.
7.16 Has ethical clearance been obtained from your institution?
Yes, informed consent will be obtained from the institution authorities and clearance from ethical committee where the study will be conducted. Also informed consent will be obtained from objects, privacy, autonomy, confidentiality and anonymity will be guarded. Scientific objectivity of the subjects will be maintained with honesty and impartiality.
8. LIST OF REFERENCES:
David Leaper. “Post-operative Complications (Oxford Specialist Handbooks)”. second edition, New York. Oxford University Press. March 2010.
Mark Greenberg. “Hand Book of Neurosurgery”. Seventh Edition. Thieme publishers. February 2010.
Caroline Bunker Rosdahl. “Text book of basic Nursing”. Ninth Edition, Lippincott Williams & Wilkins,
Suzanne C Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H Cheever. “Brunner and Suddarth's textbook of medical-surgical nursing”. Tenth Edition. Lippincott Williams & Wilkins, 2009
Nancy Bergstrom, Richard M. (CON) Allman, M. Alisan (CON) Bennett. “Treatment of Pressure Ulcers: Clinical Practice Guideline”. First edition. Diane Publishing, 2004.
P Sanal Kumar, Chandran. “An Atlas of Craniocerebral Trauma”. 1st edition. New Delhi, Jaypee brothers medical publishers (p) Ltd. 2002..
Joyce M. Black, Jane Hokanson Hawks. “Medical surgical Nursing – Clinical management for positive outcome”. Seventh edition. volume 2. Elsevier Publications, 2005.
B.T.Basavanthappa, ”Nursing Research “Second Edition ,Jaypee, 2008