CHAPTER 1

INTRODUCTION

1 Background

Kidney disease is a disease in which kidney function has

decreased until finally no longer able to work at all for the screening of
the body's electrolyte disposal, maintain fluid balance and body
chemicals such as sodium and potassium in the blood or urine
production. Kidney failure develops slowly towards a worsening of the
kidney where absolutely no longer able to work as its function. In the
world of medicine known two types of kidney failure is acute renal
failure and chronic renal failure (Wilson, 2005). Chronic kidney disease
is a disorder of renal function is progressive and irreversible failure
where the body's ability to maintain metabolism, fluid and electrolyte
balance, and causes uremia (retention of urea and other nitrogen
garbage in the blood) (Smeltzer & Bare, 2002).

Chronic kidney disease is a multifactorial disease. The cause of

chronic kidney disease varies from one country to another. (Suwitra K.
2009). The cause of chronic kidney disease is most often in the
developed countries like the United States are diabetic nephropathy,
while the cause of chronic kidney disease in developing countries is a
chronic glomerulonephritis and interstitial nephritis (Fauci.2012,
Barsoum, R.S.2006). There are several risk factors that can lead to
chronic kidney disease such as hypertension, diabetes mellitus, age,
family history of chronic kidney disease, obesity, cardiovascular
disease, low birth weight, autoimmune diseases such as systemic
lupus erythematosus, drug intoxication, systemic infection, tract
infections bladder, urinary tract stones and congenital kidney diseases
(Fauci.2012, Krol, GD 2011).

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 Health development is essentially directed effort so that every
resident can realize optimal health status. That effort is still a
constraint due to the high health problems, especially those relating
to diseases that can hinder a person's ability to live a healthy life.
Such diseases include chronic renal failure (CRF) (Depkes RI, 2002).
WHO estimates that every 1 million souls there are 23-30 people
suffering from chronic renal failure per year. Cases of CRF in the world
increased over 50% per year (Wijaya, 2010). The prevalence of
chronic kidney disease are expected in 2025 in Southeast Asia, the
Mediterranean and the Middle East and Africa will reach more than
380 million people (Suwitra K. 2009). Indonesia is among countries
with the level of patients with kidney failure are quite high. Results of
a survey conducted by the Association of Nephrology Indonesia
(Pernefri) there were an estimated 12.5% of the population or 25
million inhabitants decreased kidney function (Nurchayati S. 2010).

2 Problem Formulation
Based on the description of the above background, the problem can be formulated as
follows:
1. What is the definition of Chronic Renal Failure?
2. What are the etiology of Chronic Renal Failure?
3. How pathophysiological Chronic Renal Failure?
4. Any diagnosis of Chronic Renal Failure?
5. What are the clinical manifestations of Chronic Renal Failure?
6. How is the management of Chronic Renal Failure?
7. What about complications due to Chronic Renal Failure?
8. How is the assessment of Chronic Renal Failure?
9. What are the nursing diagnoses of Chronic Renal Failure?
10. Any intervension Chronic Renal Failure?
11. Any implementation of Chronic Renal Failure?
12. Any evaluation of Chronic Renal Failure?

3 Purpose
1 Know and understand the definition of Chronic Renal Failure.
2 Knowing and understanding of the etiology of Chronic Renal Failure.
3 Knowing and understanding the pathophysiologic about Chronic Renal Failure.
4 Know and understand about the diagnosis of Chronic Renal Failure.

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 5 Knowing and understanding about the clinical manifestations of Chronic Renal
Failure.
6 Knowing and understanding about the management of Chronic Renal Failure.
7 Knowing and understanding about the complications of Chronic Renal Failure.
8 Knowing and understanding about the assessment of Chronic Renal Failure.
9 Knowing and understanding of nursing diagnoses Chronic Renal Failure.
10 Knowing and understanding on the intervension Chronic Renal Failure.
11 Knowing and understanding on the implementation of Chronic Renal Failure.
12 Knowing and understanding about evaluation Chronic Renal Failure.

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 CHAPTER II

LITERATURE REVIEW

A BASIC CONCEPTS OF MEDICAL

1 Definition Chronic Renal Failure
Chronic Renal Failure or End-Stage Renal Disease ( ESRD ) is a progressive,
irreversible deterioration in renal function in which the bodys ability to maintain
metabolic and fluid and electrolyte balance fails, resulting in uremia ( a syndrome
resulting from an exess of urea and other nitrogenous wastes in the blood ), It may be
caused by chronic glomerulonephritis ; pyelonephritis; uncontrolled hypertension ;
hereditary lesions, such as in polycystic kidney disease; vascular disorders ; obstruction
of the urinary tract ; renal disease secondary to systemic disease ( diabetes ); infection;
drugs ; or toxic agents.
The term chronic renal failure (CFR) describes a worsening, progressive and
irreversible loss of a patients kidney function. Loss of renal function characterized by a
glomerular fitration rate (GFR) less than 20% of normal. The final stage of chronic
renal failure (slow, progressive loss of kidney function and glomerular fitration); ends
fatally with uremia.
Environmental and occupation agents that have been implicated in chronic renal
failure include lead, cadmium, mercury, and chromium. Dialysis or kidney
transplantation eventually becomes necessary to maintain life.

2 Etiology
Most common cause of chronic renal failure are diabetic neuropathy,
hypertension, glomerulonephritis, systemic lupus erythematosus, and cystic kidney
disease.

3 Pathophysiology
As renal function declines, the end products of protein metabolism, which are
normally excreted in urine , accumulate in the blood. There are imbalances in the body
chemistry and in the cardiovascular, hematologic, gastrointestinal, neurologic, and
skeletal systems. Skin and reproductive changes are also seen.

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 The patients tends to retain sodium and water, increasing the risk of edema
formation, congestive heart failure, hypertension, and, occasionally , ascites.
Hypertension may also result from activation of the rennin-angiotensin axis and the
concomstant increased aldosterone secretion.
Other patients have a tendency to lose salt, and they run the risk of hypotension
and hypovolemia. Episodes of vomiting and diarrhea may produce sodium and water
depletion, which vorsens the uremic state. Metabolic acidosis occurs as a result of the
reduced ability of the kidney to excrete hydrogen ions, produce ammonia, and conserve
bicarbonate.
The bodys serum calcium and phosphate levels are reciprocal; as one rises, the
other decreases in the serum phosphate level and a reciprocal or corresponding
decrease in the serum calcium level. Secretion of parathormone increases in response to
this decreased calcium level. However, in renal failure, the body does not respond
normally to the increased secretion of parathormone, and, as a result, calcium leaves the
bone, ooften producing bone changes and bone disease. Uremic bone disease ( renal
osteodystrophy ) develops from changes in calcium, phosphate, and parathormone
balance. Also, the active metabolite of vitamin D ( 1,25-dihydroxy-cholecalciferol )
normally manufacture by the kidney decreases with the progression of renal disease. In
other patients, the calcification process in the bone may fail, resulting in osteomalacia.
The serum magnesium level may rise because of the inability of the kidney to excrete
magnesium.
Anemia develops as a result of inadequate erythropoietin production, the
shortened life span of red blood cells, nutritional deficiencies, and the uremic patients
tendency to bleed, particularly from the gastrointestinal tract. Erythropoietin, a
substance normally produced by the kidney, stimulates bone marrow to produce red
blood cells. In renal failure, erthyropoietin production decreases and profound anemia
results, producing fatique, angina, and shortness of breath.
Neurologic complications of renal failure may occur as a result of renal failure
itself, severe hypertension, an electrolyte embalance, water intoxication, and drug
effects. Such manifestations include altered mental function, changes in personality and
behavior, convulsion, and coma.

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 A decrease in libido, impotence, and amenorrhea may occur; homever, pregnancy
in the patient with chronic renal failure is possible. Skin changes include pruritus ( in
part from calcium/phosphate Imbalance), which adds to the patients distress.
The rate of decline in renal function and progression of chronic renal failure is related
to the underlying disorder, to the urinary excretion of protein, and to the presence of
hypertension. The chronic renal failure of those patients who excrete significant
amounts of protein or have elevated blood pressure tends to progress moe rapidly than
that of patients without these conditions.

4 Diagnostic and laboratory findings

1) Urinalysis shows fixed specific gravity approximately 1.010, equivalent to plasma;
abnormal proteins, blood cells, and casts are present
2) Elevated creatinine and BUN
3) Decreased creatinine clearance
4) Abnormal electrolyte values as noted above
5) Moderate anemia
6) Decreased platelets
7) Decreased renal size by ultrasonography
8) Positive renal biopsy if damage caused by cancer

5 Clinical Manifestations
Although at time the onset of chronic renal failure is sudden, in the majority o
patients it begins with one or more symptoms-fatigue and lethargy,headache, general
weakness, gastrointestinal symptoms ( anorexia, nausea, vomiting, diarrhea ) bleeding
tendencies, and mental confusion. There is decreased salivary flow, thirst, a metallic
taste in the mount, loss of smell and taste, and parotitis or stomatitis. If active treatment
is begun early, the symptoms may disappear. Otherwise , these symptoms become more
marked, and others appear as the metabolic abnormalities of uremia affect virtually
every body system.
6 Management
The goal of management is to retain kidney function and maintain homeostatis for
as possible. All factors that contribute to the problem and those that are reversible (e.g,.
obstruction ) are identified and treated.
With the deterioration of renal function, dietary intervention is necessary with careful
regulation of protein intake, fluid intake to balance fluid losses, sodium intake to
balance sodium losses, and some restriction of potassium. At the same time, adequate
calorie intake and vitamin supplementation must be ensured. There is come restriction

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 of protein because urea, creatinine, uric acid, and organic acids- the breakdown
products of dietary and tissue protein will accumulate rapidly in the blood when there
is impaired renal clearance ( the ability to remove or clear these substances from the
blood ). The allowed protein must be of high biologic value : dairy products, eggs,
meats. High- biologic-value protein are those that are complete proteins and supply the
essential amino acids that are necessary for growth and cell repair. Ussualy, the flui
allowance is 500 to 600 ml of fluid more than the 24 hour urine output.
Sodium and potassium allowance is determined by concentrations of these electrolytes
in the serum and urine. If a patient has a tendency to lose sodium, appropriate
supplementation is given. Hyperphosphatemia and hypocalcemia have in the past been
treated with aluminium-based antacids that bind dietary phosphorus in the
gastrointestinal tract. However, concern about the potential long-term toxicity of
aluminum and the association of high aluminum levels with neurologic symtoms and
osteomalacia have led some physicians to prescribe calcium carbonate in place of high
doses of aluminum based antacids. This medication also binds dietary phosphorus in
the intestinal tract and permits the use of smaller doses of antaids. Both calcium
carbonate and phosphorus-binding antacids must be given with ood to be effective.
Calories are supplied by carbohydrates and fat to prevent wasting. Vitamin
supplementation is necessary because a protein-restricte diet does not give the
necessary complement of vitamins.( Also, the patient on dialysis may lose water-
soluble vitamins from the blood during the sialysis treatment.)
Hypertension is managed by intravascular volume control and a variety of
antihypertensive medications. The metabolic acidosis of chronic renal failure usually
produces no symptoms and requires no treatment; however, sodium bicarbonate
suplements or dialysis may be needed to corret the acidosis.
The patient is observed for early evidence of neurologic abnormalities. These may vary
from slight twitching to headache or delirium. The patient is protected from injury
during involuntary movements; thus, it is advisable to pad the side rails of the bed. The
onset of seizures is recorder along with their type, duration, and general effect on the
patient. The physician is notified immediately. Intravenous diazepam ( Valium ) or
phenytoin (Dilantin) is usually given to control seizures. Heart failure, infection, and
volume depletion may also require treatment.

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 Management of anemia has benefited from the recent availability of recombinant
human erythropoietin (Epogen ). The patient with chronic renal failure who has a low
hematocrit ( less than 30% ) usually experiences significant symptoms of the anemia
and is a candidate for this therapy. Hematocrit levels are used to assess the patient,s
response to therapy. The goal of therapy is to obtain and maintain a hematocrit of 33%
to 38%; which generally results in alleviation of the patients symptoms of anemia. A
rise in the level of the hematocrit may take 2 to 6 weeks to occur.

7 Complications
Cronic renal failure has a variety of deleterious effects on the nervous system. The
mechanism of these effects is multi factorial and is due to a combination of uremia,
disturbances of electrolytes and water balance, impaired drug metabolism, anemia,
associated comorbid illness, and the effects hemodialysis.

B BASIC CONCEP OF NURSING

1 Assesment
a. Asses fluid status and help patients limit fluid intake to prescribed limit
b. Asses nutritional status and address factors contribuiting to nutritional imbalance
assess patients understanding about the condition and it treatment , explain renal
function and assist patients to identifity ways incorporate lifestyle changes related
to illness in treatmen.
c. Asses factor contribuiting to fatigue
d. Asses patients and familys responses and reaction to illness and treatment.
Encourage open discussion of concern abaout change produced by disease and
treatment

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 e. Asses and monitorcollaborative problems (eg, hyperkalemia, pericarditis,
pericardial effusion and pericardial temponade, hyprtension, anemia, bone disease
and metastasic calcification)

2 Nursing Diagnosis
a. Fluid volume excess and electrolyte imbalancerelated to decreased urine, output ,
and dietary and fluid restrictions.
b. Altered nutrition : less than body requirements, related to anorexia, gastrointestinal
discomfort, and restrictions.
c. Knowledge deficit regarding condition and treatment regiment.
d. Activity intolerance related to fatigue.
e. Self-esteem disturbance related to dependency and role changes

3 Nursing Interventions
a Nursing Diagnosis : Fluid volume excess and electrolyte imbalancerelated to
decreased urine, output , and dietary and fluid restrictions.
Goal : Maintenance of fluid and electrolyte balance

No Interventions Rational
1 Assess fluid and electrolyte status : Assessment provides baseline and
a. Serum electrolyte levels con tinuing data base for monitoring
b. Daily weight changes
changes and evaluating interventions
c. Precise intake and output balance
d. Skin turgor and presence of edem for disturbances in fluid balance,
e. Distention of neck veins
sodium balance, and potassium and
f. Blood pressure and pulse rate and
calcium balance
rhytym
g. Signs of calcium imbalance
( chvosteks and trousseaus signs )
h. Respiratory rate and effort
2 Identify potential sources of flids : Unrecognized sources of excessive
a. Medication fluid, sodium, potassium, and
b. Foods
phosphate may be uncovered.
c. Itravenous fluids used to administer
antibiotics
d. Luids used to ingest oral medication
3 Explain to patient and family rationale Understanding promotes patient and
for restrictions of certain foods and family cooperation with necessary
fluids. food and fluid restrictions

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 4 Assist patient and family in identifying Independence and involvement of
hidden sources of restricted electrolytes patient and family in maintaining
fluid and dietary restrictions are
encouraged
Administer antacids as prescribed Antacids promote binding of
phosphate in intestinal tract and
5
normal calcium and phosphorus
levels.
6 Avoid use of magnesium-based antacids Magnesium toxicity is avoided
and other medications with magnesium
7 Provide foods and pluids within dietary Adequate dietary intake and fluid
restrictions and electrolyte balance are promoted
8 Assist patient to cope with the Increasing patient comfort promotes
discomforts resulting from restrictions. compliance with dietary restrictions.
a. Provide or encourage frequent oral a. Oral hygiene minimized dry oral
hygiene. mucous membranes.
b. Encourage use of distraction b. Focus on food and fluid
restrictions is reduced

b. Nursing Diagnosis : Altered nutrition : less than body requirements, related to

anorexia, gastrointestinal discomfort, and restrictions.
Goal : Maintenance of adequate nutritional intake

No Nursing intervension Rational

1 Assess nutritional status : Baseline data are provided for
a. Weight changes monitoring changes and evaluating
b. Laboratory value
interventions
2 Asses patients nutritional dietary Past and present dietary patterns can
paterns: be considered in planning meals.
a. Diet history
b. Food preferences
c. Calorie counts
3 Asses for factor contributing to altered Information about others factors that
nutritional intake: may be altered or eliminated to
a. Anorexia promote adequate dietary intake
b. Nausea and vomiting
provided.
c. Unpalatable diet

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 d. Depression
e. Lack of understanding of dietary
restriction
f. Stomatitis
4 Provide patients food preferences Increased dietary intake is
withing dietary restrictions. encouraged.
5 Promote intake of high biologic value Complete protein are provided for
protein foods: eggs, dairy products, positive nitrogen balance necessary
meat. for growth and tissue healing withing
protein restriction
6 Encourage high-calorie, low-protein, This diet eliminated/reduces sources
low-sodium, and low-potasium snacks of restricted foods and provides
between meals. calories for energy while sparing
protein for growth and tissue healing.
7 After schedule of medication so that Ingestion of medications immediately
they are not administrated immediately before meals may produce anorexia
before meals. or a feeling of fullness that may
interfere with dietary intake ( antacid
given to bind phosphate in the
intestinal tract and reduce the serum
phosphatelevel frequently produce a
feeling of fullness.)
8 Explain rationale for dietary restrictions Promotes patient understanding of
and their relationship to kidney relationship between diet and urea
dysfunction and increased urea and and creatinine levels to disturbed
creatinine levels. kidney fungtion.
9 Provide written lists of foods allowed List provide a positive approach to
and suggestion for improving their taste dietary restriction and reference for
without the use of sodium or potassium the patient and his family to use when
at home.
10 Provide written lists of foods that are to List include those foods that must be
be used in limited amounts or avoided avoided to prevent serious electrolyte
entirely. and nutrional problems.
11 Explain changes in diet and more liberal Frequent dialysis removes waste

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 dietary intake if dialysis is initiated. product (e.g.,urea, creatinine); protein
is removed by peritoneal dialysis and
hemodialysis.
12 Provide oral hygiene before meals. Oral hygiene temporarily improved
the patients sense of taste by
eliminating waste products and
moistents mucous membranes.
13 Provide pleasant surroundings at meal- Unpleasant factors that contribute to
time. patients anorexia are eliminated.
14 Weigh patient daily. Nutrional status can be monitored.
15 Asses for evidence of inadequate protein Inadequate protein intake can lead to
intake: decreased albumin and other plasma
a. Edema formation proteins, edema formation, and delay
b. Delayed healing
in healing.
c. Decreased serum albumin levels

c. Nursing Diagnosis: Knowledge deficit regarding condition and treatment regiment.

Goal: Increased knowledge about condition and related treatment.

No Nursing intervension Rational

1 Asses knowledge and understanding Baseline information is provided
of cause of renal failure, for further explanation and
consequences of renal failure, and its teaching.
treatment:
a. Cause of patients renal failure
b. Meaning of renal failure
c. Understanding of renal fungtion
d. Relationship of fluid and dietary
restrictions to renal failure
e. Rational for substitute for kidney
function (hemodialysis, peritoneal
dialysis, kidney transplantasion)
2 Provide explanations of renal function Patient can learn about renal
and consequences of renal failure at failure and its treatment as he
patients level of understanding in becomes ready to understand and
language understood by patient and accep the diagnosis and its
guided by patients level of readiness. consequences.

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 3 Assist patient to identity ways to Patient can see that his life does
incorporate changes and treatment not have to change completely or
into life. revolve around his disease and its
treatment.
4 Provide verbal and written Patient has information that he
information and instructions as can refer to for futher clarification
appropriate about: during hospital stay and at home.
a. Renal function and failure
b. Fluid and electrolyte restriction
c. Dietary restriction
d. Medication schedule
e. Reportable problems, signs and
symptoms
f. Follow-up schedule
g. Community resources
h. Treatment options

d. Nursing Diagnosis: activity intolerance related to fatigue

Goal: participation in activity within tolerance

No Nursing intervention Rational

1 Asses factors contributing to fatigue: Indication of severity of fatigue
a. Anemia are provided
b. Fluid and electrolyte imbalances
c. Accumulation of end products of
metabolism (e,g., urea and creatinine)
d. Depression
2 Promote independendence in self-care Mild/moderate activity and
activities within patients activity tolerance improved self-esteem are
promoted..
3 Encourage alternating activity with rest Activity and exercise within
limits are promoted and adequate
rest encouraged.
4 Assist with self-care activities when Adequate hygiene and
fatigued. opportunity for rest are promoted
5 Assist patient to determine which activities Patient can use energy to
are of most value to him. participate in those activities and

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 events of most importance to him

e. Nursing Diagnosis: self-esteem disturbance related to dependency and role changes.

Goal: improved self-concept

No Nursing intervension Rational

1 Asses patiens (and familys) responses and Data are provided about
reaction to illness and its treatment. problems encountered by
patient and family in coping
with changes in life and life-
style.
2 Assess relationship of patient and significant Strengths and supports of
family members. patients and family are
identified.
3 Asses usual coping patterns of patient and Coping patterns that may have
family members. been effective may be
potentially destructive in view
of restrictions imposed by renal
failure and its treanment.
4 Encourage patient and family to express Patient can identify concerns
concerns and reaction to changes produced and steps necessary to deal with
by renal failure and its treatment: them.
a. Role changes
b. Changes in life-style
c. Changes in occupation
d. Sexual changes
e. Dependence on health care team
f. Altered food and fluid patterns
g. Lack of energy
5 Assist patient and family in seeking Additional source of support
professional counseling to deal with severe and strength to deal with
reactions if necessary. complex reactions and feeling
is provided.
6 Provide realistic descriptions of treatment The patient and family have the
options (hemodialysis, peritoneal dialysis, data to assist in making
transplantation) to patient and family. decisions about treatment

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 options in a posiive, future-
oriented manner.

4 Implementions
Implementation in nursing proses is to translate the planning into practice
according to the principles of nursing. With implementation, plans remain theoretical.
Implementation is the initiation and completion of actions necessary to achieve the
objectives defined in the planning stage. It involves communication of the plan to all
those participating in the patients care. The interventions can be carried out by
members of the health team, the patient, or the patients family.
In implementation stage, the nurse continues to collect data regarding the patients
condition and interaction with the environment. Implementation also includes recording
the patients care on the proper documents. The documentation verifies that the plan of
care has been carried out and can be used as a tool to evaluate the effectiveness of the
plan of nursing care.
5 Evaluations
a Showed maintenance of fluid and electrolyte balance.
1) Exhibits normal or acceptable serum electrolyte levels.
2) Demonstrates no rapid weight increases or rectriction.
3) Maintains dietary and fluid intake within rectrictions.
4) Exhibits normal skin turgor without evidence of edema.
5) Exhibits normal blood pressure.
6) Exhibits regular pulse rhythim.
7) Exhibits no distention of neck veins.
8) Reports no difficulty breathing or shortness of breath.

b. Showed maintenance of adequate nutritional intake.

1) Identifies foods within dietary restrictions that are appealing.
2) Consumes high biologic value proteins.
3) Consumes foods high in calories within other dietary allowances.

c. Showed Improved knowledge about the condition and treatment related.

1) reports increased appetite at mealtime.
2) Takes antacid on a schedule that does not produce a feeling of fullness before
meals.
3) Explain in own words the rational for dietary restriction and relationship of
dietary restriction to urea and creatinine levels.
4) Consults written lists of acceptable foods when selecting foods.
5) Identifies ways of increasing foods palatability withous using sodium or
potassium.

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 6) Identifies foods that are prohibited on diet and rational for their exclusion.
7) States rational for dietary changes when dialysis is initiated.
8) Uses oral hygine before each meal.

d. Show participation in activities within the tolerance.

1) Participates in increasing levels of exercise and activity.
2) Report increased energy and sense of well-being.
3) Alternates rest and activity.
4) Participates in selected self-care activities.
5) Identifies activities and events of importance to him.

e. Indicates improving self-concept.

1) Identifies previously used coping styles that have been effective.
2) Identifies previously used coping styles that are no longer possible because of
renal failure and its treatment (e,g., alcohol and drug use; extreme physical
exertion).
3) Patient and family identify and verbalize their responses and feeling in reaction
to renal failure and the necessary changes in their life and life-style.
4) Seeks professional counseling, if necessary, to cope with changes resulying
from renal failure and its treatment.
5) Seeks information from nurse and other health care providers about treatment
options.
6) Identifies own strengths and those of supportive family members when
considering treatment options.
7) Takes active role in decision making about treatment options.

CHAPTER III
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 COVER

3.1 Conclusion
Cronic failure is a progressive illness which usually results from a primary renal disease
or a renal complication of a multi-system disease. The resulting fall in GFR is progressive
and treatmen aims to delay progression to end stage disease as well as treat the symptoms
experienced by the patient. Symptoms are multifactorial and involve a range of body
systems, which patients usually present in clinic. Drug therapy is often complex and the
choice and dose is tailored to specific biochemical markers and patient compliance.

Monitoring is essential and continuous multidisciplinary input is needed to ensure

patients receive the best treatment, care and advice posible.

3.2 Suggestion
This paper is very useful and interesting so that should be improved and can be used as
a reference for the review of Materials Research and as a provision in the application of
clinical practice for nursing students in particular. This paper Many Still Lack thus the
necessity for Adding a reference source from another book.

BIBLIOGRAPHY

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Jhonson Joyce Young, ECT,2008. Handbook For Brunner & Suddarths : Textbook Of Medical.
Surgical Nursing. Eleventh Edition. Lippincott Williams & Wilkins : Philadelphia.
Smeltzer suzanne C and Bre Brenda B,1992. Brunner and Suddarths Textbook of Medical
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Basavanthappa BT, 2008. Community Health Nursing. Second Edition. Jaypee Brothers
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Ashley Caroline and Morlidge Clare, 2008. Introduction to Renal Therapeutics. Pharmaceutical
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