CEREBRAL PALSY (CP)

Introduction: Cerebral palsy (CP) is an umbrella term denoting a group of nonprogressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement. Scientific consensus still holds that CP is neither genetic nor a 'condition', and it is also understood that the vast majority of cases are congenital, coming at or about the time of birth, and/or are diagnosed at a very young age rather than during adolescence or adulthood.

Definition "Cerebral palsy" is a general term for a group of disorders that appear during the first few years of life and affect a child's ability to coordinate body movements. Cerebral palsy can cause muscles to be weak and floppy, or rigid and stiff. In Europe and the United States, cerebral palsy occurs in about two to four out of every 1,000 births. Babies born prematurely or at low birth weights are at higher risk. The disorder is usually caused by brain injuries that occur early in the course of development. Cerebral palsy isn't curable. However, getting the right therapy for your child can make a big difference.

Symptoms In general, children with cerebral palsy exhibit a wide variety of signs and symptoms, ranging from mild to severe. Lack of muscle coordination when performing voluntary movements (ataxia) Stiff muscles and exaggerated reflexes (spasticity) Asymmetrical walking gait, with one foot or leg dragging Variations in muscle tone, from too stiff to too floppy

 Excessive drooling or difficulties swallowing, sucking or speaking Tremors Difficulty with precise motions, such as writing or buttoning a shirt The brain injury causing cerebral palsy doesn't change with time, so the symptoms usually don't worsen with age. Other neurological disorders such as mental retardation or seizures also may occur in children with cerebral palsy. Causes Most cases of cerebral palsy are believed to be caused by problems that occur before the baby is born, although some cases have been linked to brain injuries or infections during the first few months or years of life. Doctors can't always determine the root cause of the brain damage that results in cerebral palsy. Potential causes include: Infections Cerebral palsy has been linked to a variety of infectious diseases occurring either in the mother during pregnancy or in the infant during the first few months of life.

Maternal illnesses that have been linked to cerebral palsy include: German measles (rubella). Also known as "three-day measles," rubella can be prevented with a vaccine. Chickenpox (varicella). Associated with the later development of shingles, chickenpox can be prevented with a vaccine. Cytomegalovirus. Up to 80 percent of the population has been infected with this virus, which causes flu-like symptoms, by the age of 40. Most people have mild symptoms that come and go throughout their lives. If a woman experiences her first bout of cytomegalovirus during pregnancy, it may cause birth defects.

 Toxoplasmosis. A parasite found in the soil and in the feces of infected cats, toxoplasmosis can harm the fetuses of women who are infected during pregnancy. Syphilis. A sexually transmitted disease, syphilis can harm the fetuses of infected women. Infant illnesses that have been linked to cerebral palsy include: Meningitis. Meningitis causes inflammation in the membranes that surround the brain and spinal cord. The bacterial form of the disease is the most dangerous. Viral encephalitis. Encephalitis causes inflammation in the brain itself. Viral encephalitis is the most common variety.

Congenital abnormalities Some children have cerebral palsy because their brains didn't develop properly while in the womb. In most cases, doctors don't know why this happens. In some instances, however, mutations in the genes responsible for brain development can prevent the brain from developing normally. Exposure to toxins, radiation or infections increases the risk. Strokes Although strokes are more commonly associated with older people, they can happen at any age even before birth. Strokes can occur when clots in the placenta interrupt the flow of blood to the baby. Strokes can also occur if malformed or weak blood vessels leak blood into the brain. Lack of oxygen For many years, doctors and researchers believed that cerebral palsy was caused by a lack of oxygen during birth. Now they believe that only a small number of cases are caused by problems during labor and delivery. Severe jaundice

Jaundice is common in newborns. But severe cases of untreated jaundice can harm the brain permanently and may result in cerebral palsy.

Risk factors Most children with cerebral palsy don't have any apparent problems during development in the womb and birth. But some factors may increase the risk of cerebral palsy: Premature birth. A normal pregnancy lasts 40 weeks. Babies who are born less than 37 weeks into the pregnancy are at higher risk of cerebral palsy. The earlier the baby is born, the greater the risk of cerebral palsy. Low birth weight. Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher risk of developing cerebral palsy. This risk increases as birth weight falls. Breech births. Babies who are in a feet-first position (breech presentation) at the beginning of labor are more likely to have cerebral palsy. Multiple babies. The risk of cerebral palsy increases with the number of babies sharing the uterus. If one or more of the other babies die, the chances that the survivors may develop cerebral palsy increase. Toxic substances. Babies whose mothers were exposed to toxins, such as mercury, during pregnancy are at higher risk of having cerebral palsy. Mother's health. Women who have thyroid problems, mental retardation or seizures are at higher risk of having a baby with cerebral palsy.

Complications Besides difficulty with movement and posture, cerebral palsy may result in: Contractures. This condition occurs when the muscles pull so tightly on the bones that the affected limb curls in. Severe contractures can result in joint deformities or dislocation. Malnutrition. Swallowing or feeding problems can make it difficult for someone who has cerebral palsy, particularly an infant, to get enough nutrition. Some children with cerebral palsy will have multiple handicaps and may require long term care. Some of the associated problems may include: Difficulty with vision, hearing and speech Dental problems Mental retardation Seizures Abnormal sensation or perception Urinary incontinence

Preparing for your appointment While you might first discuss your child's symptoms with your family doctor, he or she will probably refer you to a neurologist for further evaluation.

What you can do Because appointments can be brief, plan ahead and write a list that includes: Detailed descriptions of your child's symptoms Questions you want to ask the doctor

What to expect from your doctor In addition to a physical exam, your doctor may also check your child's neurological health by testing his or her: Reflexes Muscle strength Muscle tone Senses of touch and sight Coordination Balance Your child may also be screened for: Mental retardation Vision problems Hearing impairment Speech and language disorders Tests and diagnosis Early signs of cerebral palsy may be present from birth. But if signs and symptoms are mild, it may be difficult to make a definite diagnosis before the age of 4 or 5. In most cases, cerebral palsy is diagnosed by age 1 or 2. Diagnostic tests may include: Brain scans If your baby is born prematurely and is at high risk of cerebral palsy, your doctor may suggest a cranial ultrasound because it is the least intrusive of the imaging techniques used to visualize the brain. Cranial ultrasound, however, provides a less detailed image than does a CT scan or an MRI. An MRI reveals the most details, which help determine a cause and a prognosis. Cranial ultrasound. This test uses high frequency sound waves to obtain images of the soft tissues inside the skull. Cranial ultrasound is painless and takes between 15 and 30 minutes to complete.

 CT scan. This test uses a computer to combine X-ray images taken from many different angles to produce cross-sectional views of your child's brain. Scanning is painless and takes about 30 minutes. If your child can't hold still for the scanning, he or she may be given a light sedative. MRI. Using radio waves and a powerful magnet, an MRI can produce detailed images of the brain. This test is painless, but it is noisy and can take up to an hour to complete. If your child can't hold still long enough for this test, he or she may be given a sedative.

Electroencephalogram (EEG) If your child has had seizures, your doctor may recommend an electroencephalogram (EEG) to check for epilepsy. In an EEG test, a series of electrodes must be affixed to your child's scalp. The procedure is painless and records the electrical activity inside your child's brain. Lab tests Your child's blood may need to be checked to help rule out other conditions such as blood-clotting disorders that can cause strokes that may mimic cerebral palsy signs and symptoms. Lab tests may also screen for genetic or metabolic problems.

Treatments and drugs The brain abnormality or damage that underlies cerebral palsy doesn't worsen with time, but children with cerebral palsy often require long term care. The type and amount of treatment depend on how many problems your child has and how severe they are. Medications Muscle relaxants. Oral medications such as diazepam, baclofen, dantrolene and tizanidine are usually the first option to relax stiff, contracted muscles. Side effects may include drowsiness and upset stomach. Baclofen can also be

delivered directly to the fluid surrounding the spinal cord via a pump surgically implanted into the abdomen. Botulinum toxin type A (Botox). Injections of botulinum toxin directly into spastic muscles also can help relieve the muscle spasms and contractures common to cerebral palsy. However, these injections have, in rare instances, caused serious problems with swallowing and breathing, particularly in children with cerebral palsy. Therapies Physical therapy. Muscle training and exercises may help your child's strength, flexibility, balance, motor development and mobility. Braces or splints may be recommended for your child. Some of these supports are used to help with function, such as improved walking. Others may stretch stiff muscles to help prevent contractures. Occupational therapy. Using alternative strategies and adaptive equipment, occupational therapists work to promote your child's independent participation in daily activities and routines in the home, school and community. They may also address difficulties with feeding and swallowing. Speech therapy. Speech therapists help improve your child's ability to speak clearly or to communicate using sign language. They can also teach your child to use special communication devices such as a board covered with pictures of everyday items and activities. Sentences can be constructed by pointing to the pictures.

Surgical or other procedures Orthopedic. Children with severe contractures or deformities may need surgery on tendons, bones or joints to place their arms and legs in their correct positions. This can make it easier to use a walker, braces or crutches.

 Severing nerves. In some severe cases, when other treatments haven't helped, surgeons may cut the nerves serving the spastic muscles. This relaxes the muscle and reduces pain, but can also cause numbness.

Coping and support When a child is diagnosed with a disabling condition, the whole family faces new challenges. Here are a few tips for caring for your child and yourself: Foster your child's independence. Encourage any effort at

independence, no matter how small. Just because you can do something faster and quicker doesn't mean you should. Be an advocate for your child. You are an important part of your child's health care team. Don't be afraid to speak out on your child's behalf or to ask tough questions of your physicians, therapists and teachers. Find support. A circle of support can make a big difference in helping you cope with cerebral palsy and its effects. As a parent, you may feel grief and guilt over your child's disability. Your doctor can help you locate support groups, organizations and counseling services in your community. Your child may benefit from family support programs, school programs and counseling.

Prevention Most cases of cerebral palsy can't be prevented, despite the best efforts of parents and doctors. But, if you're pregnant, you can take these steps to keep healthy and minimize the possibility of pregnancy complications: Make sure you're immunized. Immunization against diseases such as rubella may prevent an infection that could cause fetal brain damage.

 Take care of yourself. The healthier you are heading into a pregnancy, the less likely you'll be to develop an infection that may result in cerebral palsy. Seek early and continuous prenatal care. Regular visits to your doctor during your pregnancy are a good way to reduce health risks to you and your unborn baby. Seeing your doctor regularly can help prevent premature birth, low birth weight and infections. Describes a group of permanent disorders of movement & posture development causing activity limitation, which is attributed

nonprogressive disturbances that occurred in the developing fetal or infant brain CP is primarily a motor disorder, but the child may also have disturbances in sensation, perception, cognition, communication, and behavior. It is the major physical disability affecting functional development in children There are four types of motor dysfunction seen w/CP: spactic, dyskinetic, ataxic, & mixed are related to the location of brain insult.

Etiology: Most cases are caused by brain insult (complications of prematurity; prenatal, perinatal, & genetic factors; & viral infection of the fetus) Injury to the immature periventricular white matter in fetuses & premature infants is thought to be the most common cause of CP

Pathophysiology: Very premature infants are at risk for intra ventricular hemorrhage associated w/birth, resuscitation, fluctuations in cerebral blood pressure, respiratory distress syndrome, & hypoxix-ischemic injury. Such stressors interfere w/the auto flow of blood to the brain, leading to the rupture of blood vessels in the developing brain. When bleeding is severe enough to invade the ventricles or brain substance, the infant is at high risk for long-term neurological problems such as CP & intellectual disabilities Clinical Manifestations: Characterized by abnormal muscle tone & lack of coordination w/spasticity found in the majority of cases Symptoms vary depending on: age, area of brain involved and the extent of brain injury Other complications: hearing, speech, language impairments & seizures. Feeding may be difficult bc of oral motor involvement, including hypotonia, w/poor sucking & swallowing coordination. Clinical characteristics: o o

Clinical Characteristics

Definitions

Hypotonia

Floppiness, increased ROM of joints, response diminished reflex

Hypertonia o o Rigidity Spasticity

Tense, tight muscles Uncoordinated, awkward, stiff movements; scissoring or

crossing of the legs; exaggerated reflex reactions

Ataxia

Irregularity

in

muscle

coordination or actions Athetosis Constant involuntary writhing motions that are more sever distally Hemiplegia Involvement of one side the body w/the upper extremities being more dysfunctional than the lower extremities Diplegia Involvement of all extremities, but the low extremities are more affected than the upper, usually spastic Quadriplegia Involvement of all extremities w/the arms in flexion & legs in extension Clinical Manifestations by type: Last page Dsg Procedures: Dx usually based on clinical findings CP is difficult to dx in the early months of life as it must be distinguished from other neurological conditions & signs may be subtle. Suspicious historical findings include an infant w/a history of prematurity (less than 1500g birth weight or less than 28wks gestation), maternal intrauterine infection, multiple birth, or anoxic event. Ultrasonography can be used to detect fetal & neonatal abnormalities of the brain such as intraventricular hemorrhage

 Neuromotor test that evaluate the presence of normal movement patterns and the absence of primitive reflexes & abnormal tone in young infants have been developed o `CT scans & MRI provide information about anatomic structures & help to define cause o Information about brain metabolic functioning can be obtained by positron emission tomography (PET), a functional MRI, single photon emission computed tomography (SPECT), or diffusion tensor imaging (DTI)

Clinical Therapy: Focuses on helping the child develop to his or her maximum level of independence. o Referrals are made for physical, occupational, & speech therapy, as well as special education to improve motor function & ability o Braces & splints, serial casting, & positioning devices (prone wedges, standers, & side-lyers) are used to promote ROM, skeletal alignment, stability, & control of involuntary movements. They also help to prevent contractures o Mobility devices such as scooters, tricycles, & wheelchairs help the child to move independently & explore the environment Surgical Interventions may be required to improve function by balancing muscle power & stabilizing uncontrollable joints: o Achilles tendon may be lengthened to increase ROM in the ankle, which allows the heel to touch the floor & thus improves ambulation. o The hamstrings may be released to correct knee flexion contractures o Other procedures may be performed to improve hip adduction or correct the foots natural position.

o A dorsal rhizotomy may be performed for spastic diplegia to cut the afferent fibers that contribute to spasticity; however some muscle weakness may result from the procedure Medications o Given to control seizures, spasms (skeletal muscle relaxants, baclofen, & benzodiazepines) Diazepam, lorazepam, clonazepam given oral Dantrolene given oral Baclofen administered orally or by intrathecal pump to decrease muscle spasticity Botulinum toxin injections (type A) into specific muscles is a new therapy that helps to temporarily control spasticity. o Minimize gastrointestinal side effects (cimetidine or ranitidine ) Nsg Considerations: Goal of nursing care is to support the early identification of children w/CP & then provide supportive care to promote cognitive, motor, & social functioning. Assessment: o Be alert whose histories indicate an risk for CP o for developmental delays at each healthcare visit o any orthopedic, visual, auditory, or intellectual deficits should be noted o For the presence of newborn primitive reflexes, which may persist beyond normal age in a child w/CP o Identify infants that appear to have an abnormal muscle tone or abnormal posture (head lag beyond 6months or age, arched back, poor trunk control & balance, toe walking or scissoring) o Asymmetric or abnormal crawling by using two or three extremities indicates a motor problem

 Hand dominance prior to 18months of age is another sign of motor problem. o Record dietary Intake & height & weight percentiles for children suspected to have or dx w/condition Nsg Dx: (depends on type of CP, child symptoms & age, & family situation o Risk for constipation r/t low intake of fiber & fluids & insufficient physical activity o Impaired tissue integrity r/t decreased physical mobility & limited selfcare ability o Impaired verbal communication r/t hearing & or speech impairment o Impaired home maintenance r/t childs developmental disability & inadequate support system o Chronic pain r/t spasticity & stretching exercises to prevent contractures o Delayed growth & development r/t lack of muscle strength or limited social interaction Planning & Implementation: o Bc CP can range from mild to severe & involve numerous manifestations, interventions need to be adapted to the child & family. o Also see Care Plan on p.1363 o Nursing care focuses on providing: Provide Adequate Nutrition: children w/CP requires high-calorie diets or supplements to diet (Rationale: bc of feeding difficulties associated w/spasticity or hypotonia). Give small amts of soft foods at a time (Rationale: many children have difficulty chewing & swallowing & are at risk for aspiration). Feeding utensils w/large, padded handles may be easier for child to use. Make sure child gets adequate fluids (Rationale: child may not be able to communicate thirst). Children w/severe CP may require a gastrostomy tube (Rationale: to obtain adequate nutrition). Adequate fiber is

needed (Rationale: to prevent constipation), & some may need a bowel management program (Rationale: to treat chronic constipation). Maintain Skin Integrity: take special care to protect bony prominences from friction & injury & pressure sores. Monitor splints & braces for proper fit, & skin under them for redness (if skin is red, the braces or splints should be removed & not worn until redness is gone). Proper body alignment should be maintained at all times (support child w/pillows, towels, & bolsters whether the child is in bed or chair). Use splints & braces to help support child & reduce the risk for contractures. Support the head & body of a floppy infant. Promote Physical Mobility: ROM exercises are essential to maintain joint flexibility & prevent contractures. Consult w/PT and assist w/recommended exercises for the child. Teach parents to position child to foster flexion rather than extension so that interaction w/environment can be enhanced (e.g., child can bring objects closer to the face). Encourage parents to bring the childs adaptive appliances use in the hospital; however, secure the childs appliances as it may be difficult for the family to get them replaced if lost. Refer parents to the appropriate resources for help w/the acquisition of adaptive devices. Consider the use of relaxation training to manage pain associated w/spasticity & stretching exercises. Promote Safety: teach parents importance of using safety belts w/children in strollers & wheel chairs. Determine if an adaptive car safety seat is needed so child can be safely transported. A helmet should be worn by child w/chronic seizures to protect form further injury during seizures. Promote Growth & Development: use terminology appropriated for childs developmental level. Help child develop a positive self image to ensure emotional health & social growth. Children w/hearing impairment may need referral to learn American Sign Language or other communication methods. Provide audio & visual activities for the child who has quadriplegia.

Adaptive & assistive technology may be needed to promote mobility & communication. Foster Parental knowledge: teach parents about disorder & arrange session to teach them about all of the childs special needs. Teach administration, desired effects, & side effects of medications prescribed for seizures. Make sure parents are aware of the need for dental care bc enamel defects & malocclusion commonly occur in children w/CP and hyperplasia occurs when anticonvulsants are prescribed Provide Emotional Support: refer parents to individual & family counseling if appropriate. Listen to parents concerns & encourage them to express their feeling & ask questions. Explain what they can expect regarding future treatment. Work w/other healthcare professionals to help families adjust to this chronic disease Care in the Community: Children w/CP need continuous support in the community. A case manager such as the parent or nurse is often needed to coordinate care. Parents may need financial assistance to provide childs needs & obtain appliances such as braces or customized wheelchair. Children need new adaptive devices, ongoing development assessment & care planning. (Please read section p.1365 to much to type and repetitive). Evaluation: effective management of constipation, identification of successful communication techniques for child, & integration of the child into school, recreation, & social activities.

Classification & Type Clinical Manifestations of Insult Spastic Cerebral pyramidal cortex Persistent

Clinical Therapy Braces & splints to

hypertonia, prevent

contractures, to manage

or rigidity that relates to braces location of brain damage scoliosis

Tract cases.

injury

(75%) (e.g.,

hemiplegia,

diplegia, or quadriplegia) Tone-reducing casts to Exaggerated deep tendon keep spastic muscle in reflexes Leads to contractures & abnormal curvature of Static spine devices to positioning promote stretched position

Dyskinetic

Abnormalities of muscle skeletal alignment

Extrapyramidal, basal tone that affect entire Adaptive equipment for ganglia Injury (10-15%) cases. body Involuntary movements Tremors, w/fine & difficulty Surgery purposeful tendons, spasticity to lengthen reduce mobility & positioning

motor movements Exaggerated posturing

May exhibit rigid muscle Diazepam, tone when normal or awake & dantrolene decreased spasticity to

baclofen, control

muscle tone when sleep; inconsistent muscle tone Nerve blocks that may change hour to hour or day to day Ataxic Cerebellar (extrapyramidal) Injury (5-10%) cases. Abnormalities voluntary involving Botulinum toxin

of injections into the nerve movement muscle junction to & control spasticity Physical & occupation controlling therapy to promote

balance

position of the trunk & limbs Difficulty

hand & arm movements improved muscle tone & during reaching better motor control for

(overshooting or past- function pointing) Increased or decreased Speech muscle tone Hypotonia in infancy Muscle instability & designed to & & promote reduce joint address problems therapy oral to motor

wide-based unsteady gait Carefully Mixed Injuries areas to no dominant motor seating function compensatory contractures

multiple pattern unique

movements & posture to deformities maintain specific deficits combination of intervention control over Mobility optionswalker,

neuromotor tricycle, wheelchair

characteristics from other Early types programs

Individualized education plan

Assistive

technology

such as a computer

TEMPORAL BUT NOT SPATIAL VARIABILITY DURING GAIT IS REDUCED AFTER SELECTIVE DORSAL RHIZOTOMY IN CHILDREN WITHCEREBRAL PALSY
Bakir MS, Gruschke F, Taylor WR, Haberl EJ, Sharankou I, Perka C, Funk JF. PLoS One. 2013 Source Center for Musculoskeletal Surgery, Department of Orthopaedics, Charit-Universittsmedizin Berlin, Berlin, Germany ; Center for

Musculoskeletal Surgery, Julius Wolff Institute, Center for Sports Science and Sports Medicine Berlin, Charit-Universittsmedizin Berlin, Berlin, Germany.

Abstract INTRODUCTION: Variability in task output is a ubiquitous characteristic that results from non-continuous motor neuron firing during muscular force generation. However, variability can also be attributed to errors in control and coordination of the motor neurons themselves in diseases such ascerebral palsy (CP). Selective dorsal rhizotomy (SDR), a neurosurgical approach to sever sensory nerve roots, is thought to decrease redundant or excessive afferent signalling to intramedullary neurons. In addition to its demonstrated ability to reduce muscular spasticity, we hypothesised that SDR is able to decrease variability during gait, the most frequent functional motor activity of daily living.

METHODS: Twelve CP children (aged 6.11.3yrs), who underwent SDR and performed gait analysis pre- and 12 months postoperatively, were compared to a control group of eleven typically developing (TD) children. Coefficients of

variability as well as mean values were analysed for: temporal variables of gait, spatial parameters and velocity.

RESULTS: Gait parameters of cadence (p=0.006) and foot progression angle at midstance (p=0.041) changed significantly from pre- to post-SDR. The variability of every temporal parameter was significantly reduced after SDR (p =0.0030.049), while it remained generally unchanged for the spatial parameters. Only a small change in gait velocity was observed, but variability in cadence was significantly reduced after SDR (p=0.015). Almost all parameters changed with a tendency towards normal, but differences between TD and CP children remained in all parameters.

DISCUSSION: The results confirm that SDR improves functional gait performance in children with CP. However, almost exclusively, parameters of temporal variability were significantly improved, leading to the conjecture that temporal variability and spatial variability may be governed independently by the motor cortex. As a result, temporal parameters of task performance may be more vulnerable to disruption, but also more responsive to treatment success of interventions such as SDR.

BIBLIOGRAPHY
BOK REFERENCE Parths fundamentals of pediatrics, 1st edition, jaypee publications Hockenberry Wilson Wongs Nursing care of infants and children, 8 th edition Manoj Yadav, a textbook of child health nursing, peeve publications Smeltzer, S, et al Medical-Surgical Nursing. 10th Edition Lippincott Williams andWilkins (2004) Luckman and Sorensen, Medical-Surgical Nursing. 3rd .Edition W.B. Saunders Company (1987)

JOURNAL REFRENCE http://www.ncbi.nlm.nih.gov/pubmed/23922724

WEB REFERENCE http://www.scribd.com/doc/138674455/Cerebral-Palsy http://kidshealth.org/parent/medical/brain/cerebral_palsy.html

http://en.wikipedia.org/wiki/Cerebral_palsy

MANISHA COLLEGE OF NURSING

SEMINAR ON:
CEREBRAL PALSY (CP)

SUBMITTED TO:
Prof. Mrs. C.R. Shamsheer Begum Madam M.Sc.(N) Principal Dept. of child health nursing Manisha college of nursing

SUBMITTED BY:
Mrs Nimisha Rajan M.Sc.(N), 2nd year Dept. of child health nursing Manisha college of nursing

SUBMITTED ON

MANISHA COLLEGE OF NURSING

MASTER PLAN:
CEREBRAL PALSY (CP)

SUBMITTED TO:
Prof. Mrs. C.R. Shamsheer Begum Madam M.Sc.(N) Principal Dept. of child health nursing Manisha college of nursing

SUBMITTED BY:
Mrs Nimisha Rajan M.Sc.(N), 2nd year Dept. of child health nursing Manisha college of nursing

SUBMITTED ON