y

ACUTE RENAL FAILURE

A CASE STUDY

SAMRA AMIN
BScN 1st Year
2
 TABLE OF CONTENT
[Link]. Content [Link].
1. Case Study Introduction 4

2. Objectives 6

3. Nursing Process 8

4. Nursing Assessment 12

5. Physical Examination 15

6. Laboratory Findings 19

7. Anatomy and Physiology 22

8. Acute Renal Failure (Pathophysiology) 28

9. Pathological Process 31

10. Critical Care Map 34

11. Medical and Nursing Management 36

12. Discharge Plan 41

13. References 42

3
4
 Introduction
Background:
I choose Acute Renal Failure as my case to be studied out of
curiosity. It is my 1st time to encounter this kind of case and because of
that; I was so interested in it. I was willing to do this case to challenge
my mind in analyzing the problem and to enhance my hidden
knowledge.

Case
Study Introduction

Significance of study:
The case study will help me in understanding the disease process of the
patient. This would also help the group in identifying the primary need
of the patient with. By identifying such needs and health problems we
can now formulate an individualized care plan for the patient that would
address the needs and problems effectively. Effective management of
the problems identified will help the patient to recover faster and
maintain a holistic sense of wellness even while in the hospital. This

5
case study would also provide knowledge skills and attitude on how to
manage a future patient.
Scope:
This case study was conducted in the Shalamar Hospital on 11 years old
male patient in cooperation of the patient’s family.
Goals:
I aim to develop essential as well as skillful nursing care which is
based on better and effective approach. That will serve as catalyst to
promote health, reduce illness and prevent /eliminate such infectious
diseases.

6
Case
Study Objectives

7
 Objectives

By the end of this case study we will be able to learn and discuss:

 Define what Acute Renal Failure is.

 A brief review of Anatomy and Physiology of the related body
system (Urinary system).
 Pathophysiology of Acute Renal Failure.
 What are the sign and symptoms of Acute Renal Failure?
 Medical and Nursing management of patient Acute Renal Failure.
 Prioritize things which are essential in assessing and developing
proper interventions in treating Acute Renal Failure.
 Formulation and application of nursing care by utilizing nursing
process.
 To learn and sharpen clinical skills which are required in the
management of the patient with Acute Renal Failure.
 Apply the core and fundamental systematic approach of the
nursing profession in promoting health and preventing illness.

8
Case Nursing
Study
Process

9
 Nursing Process
Nursing Health History
1. Demographic data
Name: Mr. X
Age: 30 Years Old
Sex: Male
Marital Status: Single
Nationality: Pakistani
Religion: Islam
Occupation: Student
Admission Date: 14 November 2023 – 08:37 Pm
Date of Discharge: 23 November 2023 – 12:14 Pm
Admitting Impression: Pyrexia of Unknown origin / Acute Renal Failure
Diagnosis: Acute Renal Failure

2. Case scenario and Chief complaint:

This is a case of an 30 Years Old male patient received on 16 November
2023 from Male Medical Ward to ICU of Shalamar Hospital, Lahore in
drowsy condition with chief complaints of:
 Fever from last 3 months on and off.
 Headache from last 2 months on and off.
 Vomiting and abdominal pain from last 10 days.
 Abdominal pain from 7 days.
 Irritable behavior from 3 days.
 Drowsiness from 1 day.

3. History of present illness

3 months before patient was healthy when he developed low grade fever
i.e. 100F. He started treatment with Panadol (Paracetamol) at home. But

10
after 1 month of that fever became high grade and client took treatment
from some general practitioner. Then client was having headache after 1
month of fever. Nausea and vomiting occurred 10 days before admission
in Shalamar Hospital. Then Patient came to Emergency department of
Shalamar Hospital, Lahore with high grade fever (102F) and was
diagnosed of PUO (pyrexia of unknown origin) by a ER medical officer,
Treatment given in ER was Infusion Provas and Inj. Gravinate. Then
patient was admitted in Male Medical Ward of GTHS, Lahore at 14
November 2023 – 08:37 Pm. Following treatment was given in Male
Medical Ward:
 Inj. Rociphin 2g BD
 Inj. Gravinate BD
 Inj. Omega 40g BD
 Ringer Lactate 1000ml OD
 5 % Dextrose water 1000 ml OD
 Inj. Provas 1g BD
 Inj. Decadron 2cc TDS
 Tab. Myrin P 5 Tablets OD
In Male Medical Ward patient developed drowsiness and drop in blood
pressure (90/ 60mmHg) and shifted to Intensive care unit.

4. Past medical history:

Past medical history:
There is no significant Past medical history.
Past Surgical History:
There is no significant past surgical history.
5. Family history:
FATHER MOTHER
DIABETES + -
HYPERTENSION + -

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 ASTHMA - -
PULMONARY TB + -
6. Social and Personal History:
Patient belongs to a Middle class family. He is recently
studying at intermediate level.
7. Parameters:
 Foleys Catheter
 IV line
 Cardiac Monitor
 Vital Signs 1 hourly
 Input and Output Chart

12
 Nursing
Case
Assessment
Study (Gordon’s Functional Health
Patterns)

13
 Nursing Assessment
(Gordon’s Functional Health Patterns)

This portion of the study will present normal and regressed health
functions of patient.
Health Perception and Health Management:
The patient may perceive a sudden decline in renal function, leading to
seeking medical help for managing the condition.
Nutritional-Metabolic Pattern:
Changes in dietary habits and nutritional status may be observed due to
renal dysfunction impacting fluid and electrolyte balance.
Elimination Pattern:
ARF directly affects renal elimination, leading to alterations in urine
output and potential fluid and electrolyte imbalances.
Activity-Exercise Pattern:
Limited physical activity may result from the patient's weakened state or
hospitalization, impacting overall functional ability.
Sleep-Rest Pattern:
Disruptions in sleep patterns may occur due to discomfort, hospital
routines, or complications associated with ARF.
Cognitive-Perceptual Pattern:
Neurological symptoms related to renal dysfunction could affect
cognitive function, requiring assessment of mental status.

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Self-Perception and Self-Concept Pattern:
The sudden onset of ARF may impact the patient's self-image and
perception of health, potentially leading to emotional distress.
Role-Relationship Pattern:
Changes in roles and relationships may occur due to the patient's health
status, affecting interactions with family, friends, and caregivers.
Sexuality-Reproductive Pattern:
ARF can influence reproductive health and may lead to alterations in
sexual function, requiring consideration in patient care.
Coping-Stress Tolerance Pattern:
The patient may experience stress related to the acute nature of ARF,
necessitating assessment of coping mechanisms and support systems.
Value-Belief Pattern:
Cultural and personal beliefs may influence the patient's approach to
illness and treatment, impacting decision-making and care planning.

15
Case Physical
Study Examination

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 Physical Examination
General appearance of client:
An ill looking young client lying on bead in supine position,
patient is drowsy, there is incoherent speech, appeared to be cleaned and
hygienic. There is no observable physical deformity or abnormality.
Physique:
Normal
Consciousness:
Drowsy with GCS of 12/15.
Skin:

General color Pallor

Texture Smooth
Turgor Poor
Temperature Warm
Moisture dry

Nails:

Pallor +ve
Cyanosis -ve
Clubbing -ve

Eyes:

Lids Symmetrical
Conjunctiva Pallor
Sclera Normal
Reaction to R- brisk
light L - brisk

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Nose:

Mucosa Dry
Patency Both nostrils
patent
Smell Normal
Sinuses Not tender

Mouth:

Mucosa Pink
Teeth no missing teeth
Gums pink

Vital Signs:

Temperature 101 F
Blood Pressure 110/70 mmHg
Pulse Rate 76 beats per min
Respiratory 19 breath per min
Rate

Cardiovascular System:

Heart Rate 76 beats per min

Heart sound Regular rhythm,
absent murmurs
Peripheral Regular
pulses
Capillary refill 2 sec brisk.
Blood pressure 110/70 mmHg

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Respiratory System:

Respiratory 19 breath per min

rate
Breathing Regular
pattern
Type of Abdomino –
respiration thoracic
Shape of chest Elliptical
Position of Midline
trachea
Lung expansion Symmetrical
Percussion Resonant
sound
Adventitious Absent
breath sounds

Abdomen:

Shape Normal
Scar Absent
Bowel sounds Normal

Extremities:

Deformity Absent
Range of motion Normal
Muscular tone and Fair
strength
Gait Coordinated

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Case Laboratory
Study Findings

20
 Laboratory Findings
Complete Blood Examination:

Component Reference Unit 17/11/2023 18/11/2023 19/11/2023

value
ESR 10-20 mm/hour 37 30 20
Hemoglobin 14-17 G/dl 12.3 12.6 12.1
WBC 4-11 *10.e 3/uL 3.8 9.3 7.6
RBC 4-6 *10.e 6/uL 4.95 4.95 4.71
Platelet 150-450 *10.e 3/uL 293 346 292

Renal Profile:

Component Reference Unit 15/11/2023 17/11/2023 19/11/2023

value
Urea 10-50 mg/dl 28 26 21
Creatinine 0.50-1.30 mg/dl 0.5 0.6 0.5

Serum Electrolytes:

Component Reference value Unit Patient value

Sodium 135-145 mmol/L 124
Potassium 3-5 mmol/L 4.1
Chloride 96-108 mmol/L 91
Calcium 8-10 mg/dl 7.2

Liver Function Test:

Component Reference value Unit Patient Value

Bilirubin Total 0.10-1.10 Mg/dl 0.9
Bilirubin Direct 0.10-0.40 Mg/dl 0.6
Bilirubin indirect 0.10-0.70 Mg/dl 0.4
Alkaline 80-270 U/L 220
phosphatase
SGPT 5-40 U/L 12
SGOT 5-40 U/L 15
Albumin 4-5 G/dl 4.1

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HCV:
Negative.
Typhoid:
Negative.
Malarial Parasite:
Negative.
X-Ray:
Patchy shadowing in left apex and upper zone chronic
inflammatory disease
Normal cardiac size
Diaphragm is normal
CT SCAN:
Rather effected sulci and gyri however no significant parenchymal
and meningeal enhancement at time of examination. No associated
ischemic changes or hemorrhage or any subfalcine herniation. Findings
likely represent meningitis / encephalitis partially treated.

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Case Anatomy and
Study Physiology

23
 Anatomy and Physiology

Anatomy of the Kidney:

Location:
Retroperitoneal organs located on either side of the vertebral column.
Typically, the right kidney sits slightly lower than the left due to the
liver.
Structure:
Outer Cortex: Contains renal corpuscles and renal tubules.
Inner Medulla: Composed of renal pyramids, where urine is formed.
Renal Pelvis: Funnel-shaped structure that collects urine and connects to
the ureter.
Blood Supply:
Supplied by the renal arteries, branching off the abdominal aorta.
Drained by the renal veins, returning blood to the inferior vena cava.
Nephrons:
Functional units of the kidney.
Each kidney contains about 1 million nephrons.
Composed of a renal corpuscle (Bowman's capsule and glomerulus) and
renal tubules (proximal convoluted tubule, loop of Henle, distal
convoluted tubule).

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Renal Arteries and Veins:

Renal arteries branch into smaller arteries, ultimately forming afferent

arterioles that supply blood to the glomeruli.
Efferent arterioles carry blood away from the glomeruli.
Renal veins carry filtered blood away from the kidneys.

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Ureters:
Tubes connecting the renal pelvis to the urinary bladder.
Smooth muscle contractions propel urine from the kidneys to the
bladder.
Renal Capsule:
Fibrous outer covering that helps protect the kidney from trauma.
Renal Columns:
Extensions of the renal cortex that project into the renal medulla.
Renal Papilla:
Tip of a renal pyramid, through which urine exits into the minor calyx.
Calices (Calyces):
Cup-like structures that collect urine from the papillae.
Minor calyces merge to form major calyces, ultimately leading to the
renal pelvis.
Perirenal Fat Capsule:
Adipose tissue surrounding the kidney that provides cushioning and
insulation.
Renal Sinus:
Internal cavity within the kidney.
Contains blood vessels, nerves, lymphatic vessels, and the renal pelvis.

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Interstitial Fluid:
Fluid found in the renal interstitium, providing a supportive environment
for nephron function.
Renal Cortex and Medulla Distinction:
Cortex: Outer region beneath the renal capsule.
Medulla: Inner region, consisting of renal pyramids and columns.
These details emphasize the complexity and specialized structures
within the kidneys, essential for their crucial roles in filtration,
regulation, and maintenance of physiological balance.

Physiology of the Kidney:

Filtration:
Occurs in the renal corpuscles (glomeruli).
Blood is filtered, and the filtrate enters the renal tubules.
Reabsorption:
Proximal Convoluted Tubule (PCT): Reabsorbs water, ions, and
nutrients.
Loop of Henle: Further reabsorption of water and ions.
Distal Convoluted Tubule (DCT): Fine-tunes electrolyte balance.
Secretion:

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Additional substances (e.g., drugs, ions) are actively transported into the
filtrate.
Formation of Urine:
Filtrate passes through tubules, where reabsorption and secretion occur.
Collecting Ducts: Concentrate urine by reabsorbing water.
Regulation of Blood Pressure:
Renin-Angiotensin System: Regulates blood volume and pressure.
Secretion of erythropoietin stimulates red blood cell production.
Electrolyte Balance:
Kidneys regulate levels of sodium, potassium, calcium, and other ions.
Acid-Base Balance:
Secrete hydrogen ions and reabsorb bicarbonate to maintain pH balance.
Hormone Production:
Erythropoietin: Stimulates red blood cell production.
Calcitriol: Activated form of vitamin D, important for calcium
absorption.
Understanding the intricate anatomy and physiology of the kidneys is
essential for comprehending their vital role in maintaining homeostasis
and overall health.

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Case
Study Pathophysiology

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 Pathophysiology
Acute kidney failure occurs when your kidneys suddenly become unable
to filter waste products from your blood. When your kidneys lose their
filtering ability, dangerous levels of wastes may accumulate, and your
blood's chemical makeup may get out of balance.
Acute kidney failure — also called acute renal failure or acute kidney
injury — develops rapidly, usually in less than a few days. Acute kidney
failure is most common in people who are already hospitalized,
particularly in critically ill people who need intensive care.
Symptoms
Signs and symptoms of acute kidney failure may include:

 Decreased urine output, although occasionally urine output

remains normal
 Fluid retention, causing swelling in your legs, ankles or feet
 Shortness of breath
 Fatigue
 Confusion
 Nausea
 Weakness
 Irregular heartbeat
 Chest pain or pressure
 Seizures or coma in severe cases
 Oliguria (reduced urine output) or anuria (absence of urine).
 Fluid retention, leading to edema and hypertension.
 Electrolyte imbalances, such as hyperkalemia.

30
  Elevated blood urea nitrogen (BUN) and serum creatinine levels.
Sometimes acute kidney failure causes no signs or symptoms and is
detected through lab tests done for another reason.
Muscle tissue breakdown (rhabdomyolysis) that leads to kidney damage
caused by toxins from muscle tissue destruction
Breakdown of tumor cells (tumor lysis syndrome), which leads to the
release of toxins that can cause kidney injury
Urine blockage in the kidneys
Diseases and conditions that block the passage of urine out of the body
(urinary obstructions) and can lead to acute kidney injury include:
Bladder cancer
Blood clots in the urinary tract
Cervical cancer
Colon cancer
Enlarged prostate
Kidney stones
Nerve damage involving the nerves that control the bladder
Prostate cancer
Acute renal failure (ARF), also known as acute kidney injury (AKI), is a
condition characterized by a rapid decline in kidney function, leading to
the accumulation of waste products and electrolyte imbalances in the
body.

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Prerenal Causes:
Insufficient blood flow to the kidneys, often due to decreased blood
volume or decreased cardiac [Link] like severe dehydration,
heart failure, or major blood loss can contribute.
Intrinsic Renal Causes:
Damage directly to the kidney tissue itself.
Ischemia (lack of blood supply) can result from conditions like sepsis,
severe infections, or prolonged hypotension.
Nephrotoxic drugs, contrast agents, or toxins can also damage renal
structures.
Postrenal Causes:
Obstruction in the urinary tract that hinders urine flow.
Conditions such as kidney stones, tumors, or enlarged prostate can lead
to postrenal ARF.
Pathophysiological Process:

Initiation Phase:
Triggering event causes rapid decline in renal function.
Decreased blood flow or direct injury to kidney cells.
Maintenance Phase:
Ongoing damage and dysfunction occur.
Tubular cells are particularly vulnerable, leading to impaired filtration
and reabsorption.
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Accumulation of waste products, fluid, and electrolyte imbalances.
Recovery Phase:
Repair and regeneration of damaged renal tissue.
This phase varies; some cases may result in complete recovery, while
others may lead to residual damage.

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34
Case Critical Care
Study Map (CCM)

35
 Medical and
Case
Nursing
Study Management

36
 Medical Management
SUPPORTIVE MANAGEMENT

 The goals of treatment are to provide supportive care (rest,

nutrition, fluids) to help the body fight against the infection and to
relieve symptoms.
 Reorientation and emotional support for confused or delirious
people may be helpful.
 If brain function is severely affected, interventions like physical
therapy and speech therapy may be needed after the illness is
controlled.
 Treatment is symptomatic since no effective drugs are known in
encephalitis for viral infections.
PHARMACOLOGICAL MANAGEMENT
The objectives of treatment of ARF are to restore normal chemical
balance and prevent complications until repair of renal tissue and
restoration of renal function can occur.
Pharmacologic therapy. Cation-exchange resins or Kayexalate can
reduce elevated potassium levels; IV dextrose 50%, insulin, and calcium
replacement may be administered to shift potassium back into cells;
diuretic agents are often administered to control fluid volume.
Nutritional therapy. Replacement of dietary proteins is individualized
to provide the maximum benefit and minimize uremic symptoms;
likewise, caloric requirements are met with high-carbohydrate meals,
because carbohydrates have a protein-sparing effect; foods and fluids

37
containing potassium or phosphorus are restricted; and after diuretic
phase, the patient is placed on a high-protein, high-calorie diet.
MEDICAL MANAGEMENT

 Tracheostomy (artificial respiration) is needed if respiratory

difficulties occur.
 A breathing tube, urinary catheter, or feeding tube may require if
the patient is unconscious.
PREVENTION
Acute kidney failure is often difficult to predict or prevent. But you may
reduce your risk by taking care of your kidneys. Try to:
Pay attention to labels when taking over-the-counter (OTC) pain
medications. Follow the instructions for OTC pain medications, such as
aspirin, acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB,
others) and naproxen sodium (Aleve, others). Taking too much of these
medications may increase your risk of kidney injury. This is especially
true if you have pre-existing kidney disease, diabetes or high blood
pressure.

38
 Nursing Management
Nursing interventions are aimed at restoring renal function and reducing
potential causes of increased renal injury.
Monitor fluid and electrolyte balance. The nurse monitors the patient’s
fluid and electrolyte levels and physical indicators of potential
complications during all phases pf the disorder.
Reducing metabolic rate. Bed rest is encouraged and fever and infection
are prevented or treated promptly.
Promoting pulmonary function. The patient is assisted to turn, cough,
and take deep breaths frequently to prevent atelectasis and respiratory
tract infection.
Preventing infection. Asepsis is essential with invasive lines and
catheters to minimize the risk of infection and increased metabolism.
Providing skin care. Bathing the patient with cool water, frequent
turning, and keeping the skin clean and well moisturized and keeping the
fingernails trimmed to avoid excoriation are often comforting and
prevent skin breakdown.
Provide safety measures. Patient with CNS involvement may be dizzy or
confused.
Administer oxygen.

39
High-flow oxygen or a ventilator may be necessary to increase
oxygenation for cardiac function and tissue perfusion.
Encourage bed rest.
Frequent rest is required to prevent overexertion and stress on the heart.
Group activities and assessments to reduce interruptions and maximize
sleep.
Monitor electrolytes.
Increased and decreased levels of potassium can affect the heart muscle
and cause arrhythmias. Calcium has cardiac effects and decreased levels
can enhance the toxic effects of potassium.
Administer medications as indicated.
Inotropic agents may be prescribed to improve cardiac output though
care must be taken to preserve renal function. Antidysrhythmics,
vasopressors, and blood products may be required. Monitor
administration closely to prevent fluid overload.

40
 Drug Study
Following treatment was prescribed in ICU:
o Inj. Oxidil 2g BD o Inj. Manitol 150cc TDS
o Tab. Vita-6 BD
o Inj. Omega 40 mg OD o Inj. Provas 1g BD
o Inj. Decadron 1cc TDS o Inj Gravinate SOS
o Tab. Myrin P 5 Tablets OD
o Inj Ringer Lactate 1000ml OD

Brand Generic name Mechanism of Rout Side effects

Name action
Inj. Oxidil Ceftriaxone Inhibits I/V Hypersensitivity,
bacterial cell increased liver
wall synthesis, enzymes,
leading to cell diarrhea, Rash.
death

Inj. Omega Omeprazole Gastric proton I/V Hypersensitivity,

pump inhibitor, headache,
suppress gastric diarrhea,
acid secretion abdominal
pain,trouble
awakening and

41
 sleep deprivation
[Link] Dexamethasone Antiinflamator I/V GI disturbance,
y hypertension,
glucocorticoid, edema, delayed
suppresses wound healing,
immune system susceptibility to
and stabilize infection
leucocyts

Brand Generic Mechanism of Ro Side effects Special

Name name action ut considerati
ons
Tab. Rifampicin inhibi Ora Disorders of Contraindic
Myrin Rifampic ts bacterial DNA l the blood ated in
in150mg, dependent RNA lymphatic Alcoholism
Ethambu synthesis by system, , optic
tol inhibiting immune neuritis,
275mg, bacterial DNA- system, impaired
Isoniazid dependent RNA metabolism hepatic
75mg, polymerase nutrition, , function,
Pyrazina GI severe
. Ethambutol
mide Disturbance renal
inhibits bacterial
, insufficienc
400mg cell wall
hepatobiliar y,
synthesis.
y, skin SC hyperurice
Isoniazid & tissues, mia, gouty
Pyrazinamide musculoskel arthritis,
inhibits the etal, jaundice,

42
 synthesis connective retrobulbar
of mycolic acid tissue bone, neuritis.
required for renal/urinar Pregnancy
the mycobacterial y. Fever, lactation
cell wall. malaise, flu-
like
syndrome,
dryness of
mouth.
Inj. Manitole Osmotic diuretic, I/V Dizziness, Monitor for
Manitol increase osmotic headache, electrolyte
pressure of plasma hypotension imbalance
and increase GRF , nausea, and sign
and inhibit tubular vomiting , and
reabsorption of diarrhea, symptoms
water polyurea, of
dehydration dehydration
, electrolyte .
imbalence
Brand Generic Mechanism of Rou Side effects Special
Name name action t considerat
ions
Tab. Vitamin Adjuvant therapy Oral Hypersensit Consider in
Vita-6 B in tuberculosis ivity to hypersensit
complex. patients. Proved pyridoxine. ivity to
beneficial in Nausea and pyridoxine.
correcting the vomiting
sideroblastic
anaemias. Acts as
43
 an antidote for the
seizures and
acidosis in
patients who have
ingested an
overdose
isoniazid.
Inj. Paraceta Antipyretic I/V Hepatotoxic It can
Provas mol action, act by ity, cause
inhibiting nephrotoxic serious
cycloxygenase ity, hepatotoxi
enzyme. Gestrointest city while
inal taken in
disturbance high doses.

44
 Discharge Plan
Medication:
 Cefotaxime OD.
 Claforan TDS for 2 weeks.
 Vitamin-B6 1 Tab HS.
 Omega-40mg 1 Capsule TDS for 1 month.
Environment/ Exercise:
 Instruct the family to provide clean and fresh air.
 Encourage mild exercise to promote good circulation and healthy
Self Concept.
Treatment:
 Advise patient to take medication with heavy meals and on time.
 Teach patient and his family members that adherence to prescribed
treatment is very necessary and important for total recovery of the
patient.
Health Teachings:
 Instruct patient to take adequate fluid intake up to 8 Glass per day.
 Report any worsening of condition to physician.
 Advice for the comfortable sleeping pattern.
 Continuous weight monitoring and report any sudden change in
weight.
 Instruct for bed rest with tolerable mobility.
 Instruct for the side effects of medicines, disease process and
treatment regimen.
Diet:
Diet plays an important role in the recovery of patient so instruct patient
and family to:
 To take diet as tolerated
 Eat nutritious food fruits and vegetables
 Not to eat junk and fast food instead encourage healthy foods
45


46
 References
American Pain Society. Guidelines for the management of acute and chronic pain
in sickle-cell disease. Author: Glenview, IL; 2015.

Ballas SK. Update on pain management in sickle cell disease. Hemoglobin.

2011;35(5–6):520–529.

Granerod, J., & Crowcroft, N. S. (2007). The epidemiology of acute encephalitis.

Neuropsychological rehabilitation, 17(4-5), 406–428.

K.C, V. (2019). Manual of Pathophysiology. Arcadia Publishing House Pvt. Ltd.

Mandal, G.N. (2019). A Textbook of Medical Surgical Nursing. Makalu

Publication House.

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