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1 Introduction
2
Ambulatory care
 Definition
 Modules
 ambulatory care practice setting
 Dimensions unique to nursing practice in
ambulatory care
 Nursing responsibilities.


3 Acute care and critical care.

 Acute care.
 Types of hospitals ;
 Client admission to a hospital.
 Nurses role in hospitals

 Critical care.
 Need for the admission.
 Common condition necessitating ICU
admissions
 Role of nurse.
4
Long term care.
 Long term care facilities
 Nurses role.
5
Home health care.
 patient care in the home
 home health care team
 Nurses role.
6
Conclusion.
7
Reference.
1. Introduction.
Medical field is a vast field which keeps on changing according to
the needs of the clients; as a result it has given rise to development
of new concepts such as ambulatory care, acute and critical care,
long term care, home health care.
2. Ambulatory care.
a) Definition.
Ambulatory care is any medical care delivered on an
outpatient basis. Many medical conditions do not require
hospital admission and can be managed without admission
to a hospital. Many medical investigations can be performed
on an ambulatory basis, including blood tests, X-rays,
endoscopies and even biopsy procedures of superficial
organs.
b) Modules which influence ambulation.
 Clinical model.
 :most health policy experts agree that the current
health care system is based on the clinical or medical
model .in this model health is conceptualized as the
absence of the clinical manifestations of disease .
 It is assumed that the body is a machine and that
modern medical technology can use physical and
chemical interventions to fix the machine when ever its
broken .this has led the great emphasis on expensive,
acute care with high technology treatments and
relatively little attention to prevention, public health,
environmental measures, or personal responsibility for
health.

 Levels of prevention model.

This model suggests that the natural history of any
diseases exists on continuum , with health at one end
and advanced disease at the other .this model gives
three levels of the application of preventive measures
that can be used to promote health and arrest the
disease process at different points along the
continuum. The goal is to maintain a healthy state and
to prevent disease or injury
 Primary prevention; encompasses both health
promotion and specific protection. Health promotion
includes interventions such as health education,
information on growth and development, nutrition,
and exercise as well as the provision of adequate
housing, safe working conditions, and other services.
Specific protection interventions are targeted at
specific health risks, injuries, and diseases .ex: seat
belts reduce injuries in automobile crashes. Primary
prevention may be targeted at individual clients,
families, groups, communities, or population.

 Secondary prevention: secondary measures include

early diagnosis and prompt treatment as well as
disability limitation .case finding, screening, and
treatment of disease by medical or surgical
interventions to arrest the disease process and prevent
further complications are all part of secondary
prevention. An ambulatory care nurse carrying out a
multiphase health screening for hypertension,
diabetes, and hypercholesterolemia would be
practicing secondary prevention.
 Tertiary prevention: it is the provision of measures to
rehabilitate a person or group so they can maximize
their remaining capacities .cardiac rehabilitation
nurses, physical and occupational therapists and
many home care nurses focus on tertiary prevention.
E.g. teaching crutch walking.
 Primary health care, primary care, and managed care
models.
Primary health care focuses on the universal right
to basic health care. Primary care focuses on integrated
care coordinated by one primary provider .managed
care approaches the use of health care services from a
cost containment perspective .primary prevention of
often confused with the concepts of primary care
providers, such as family practice physicians and nurse
practioners, in a gatekeeper function, causing further
confusion.

c) ambulatory care practice setting :health statistics

classifies ambulatory care settings into three main
groups :
 physicians office :
This is the most common site for the delivery
of ambulatory care. Physicians of many specialties
deliver ambulatory care. These physicians include
specialists in family medicine, internal medicine,
obstetrics, gynecology, cardiology, gastroenterology,
endocrinology, ophthalmology, and dermatology.
 Physician’s group practices usually operate on for a
profit basis and seek fee for service payment directly
from clients or through third party payers such as
insurance companies etc.
 In a fee for service system, providers get paid
separately for each service they provide, more service
they give, more revenue they get.
 In integrated delivery system, hospitals align with
several physician group practices to increase the
hospital referral rate and provide increased
coordination of care.
 The role of the ambulatory care nurse in physician
group practices is evolving to meet the need for
increasingly skilled technical services, especially in
specialty practices such as oncology, and surgical
centers.

 community hospital out patient department:

 community hospital clinic services began in the
latter part of the 19th century and took over functions
of free standing dispensaries
 ambulatory services may be housed adjacent to the
hospital or be freestanding in the community .services
may include outpatient surgery ,emergency centers,
cardiac rehabilitation centers , drug and alcohol
treatment programs, oncology health centers, home
care, hospice ,and community health promotion .
 Specialized clinics and health promotion programs
staffed by nurses also with in community hospital
outpatient settings.
 teaching hospital out patient department :
 These departments of teaching were developed to fulfill
the mission of academic health centers to provide
medical and other health professional education,
biomedical research, and client care services.
university hospital outpatient departments and most
large hospitals run by local governments provide
learning experiences for medical, nursing , and other
health science students as well as opportunities for
clinical research on population s of clients with highly
specialized needs .veterans administration
ambulatory care departments serve a similar function.
most teaching hospitals maintain a nonprofit status
and provide care for those with public or private
insurance as well as uncompensated care for
uninsured clients
 Nurses play a major role in client and family teaching
and as case managers for clients with catastrophic
and chronic illnesses.

 Emergency department :
Almost all of ambulatory care visits are provided in
emergency departments (when there is no opd ).they
may come in ambulance or by themselves .because
emergency departments are organized according to the
clinical nodal and are set up to meet acute care needs
they are far from the ideal place to provide primary
care services.
 Other ambulatory care settings.
One unique type of ambulatory care organization is a
nurse managed center or nursing center. these nurse
staffed community centers may provide primary health
care services , home care , hospice ,college health
services, work site health promotion ,school nursing or
wellness services .many nursing centers were
developed by schools of nursing as faculty practice
sites for undergraduate and graduate students.
Other settings in which ambulatory care nurses
practice include government funded public health
clinics, migrant and community health centers,
homeless shelters, school based health centers.

 Dimensions unique to nursing practice in ambulatory

care.

 Telehealth nursing practice

It is defined as “nursing practice using the
nursing process to provide care for individual patients
or defined patient populations through
telecommunications media.
Criteria for the telenursing practice:
o Using protocols, algorithms, or guidelines to
assess and address client needs
systematically.
o Prioritizing the urgency of client needs.
o Developing a collaborative plan of care with
clients and their support systems the plan of
care may include wellness promotion,
prevention education, care counselling, disease
state management, and care coordination.
o Evaluating outcomes of practice and care.

Communication by telephone for health

guidance is common in pediatrics, obg, and
primary care practices.
According to nursing intervention classification
telephone nursing intervention is of four types.

o Telephone consultation. Here nurses assess

the clients need and readiness to learn, teach
clients, and provide advice based on protocols
approved for use with telephone nursing
practice.
o The nurse must have expert communication
skills to elicit information when no visual or
physical assessment cues are available
.although telephone assessment has some
pitfalls, there are some benefits, too.

o Telephone follow up :is used for clients who

have had ambulatory surgery or complex
treatments .the nurse calls the client within a
specified period to assess how well the client is
recovering and to provide guidance for any
problems .especially when the nurse is calling
the client , the nurse must protect the
confidentiality of the client and should speak
with family members or significant others only
if the client has given permission .and it gives
the client ready access to a health
professional.
o Telephone triage: clients are sorted by
telephone encounter based on the immediacy
of the need and the type of problem .in
ambulatory care ,a nurse talks with a client
calling from home and assess the type of
problem, how the problem should be resolved,
whether the client should be seen in person
and when , and who should resolve the
problem.
o Telephone surveillance: it is to work with
data coming into a central ambulatory site
from monitoring equipment used by clients at
home .for ex .cardiac monitoring can be
accomplished by connecting the monitoring
equipment to a computer or telephone in the
client’s home.
Here as a nurse our role is to document on
the client’s medical record, including
assessment, analysis, recommendations
made to the client, and the client’s level of
understanding of instructions.

 Expert practice within setting

Ambulatory care nurses who develop expertise with
specific client populations often are in charge of nurse
run clinics such as incontinence clinics, or wound
care clinics. In a nurse run clinic, a nurse with at least
a bachelors degree in nursing, plus experience and
continuing education, works with physicians to
develop protocols. Nurses monitor clients during
ambulatory visits and suggest interventions for
common problems that clients experience.
The nurse often acts as their advocate in the health
care system .nurses find this type of work rewarding
because they have ling term relationships with clients
and families and can see the results of their
teaching ,advocacy ,and nursing interventions.

 Ambulatory care interdisciplinary team.

Nurse working in ambulatory settings are members
of an interdisciplinary team .they work collaboratively
with physicians ,midlevel providers, such as nurse
practioners ,nurse midwives, and physician
assistants ,LPN”S and licensed vocational nurse
,medical assistants ,and clerks receptionists .

 Professional and legal considerations.

o Standards of care.
There are nine standards which are developed
by AAACN. i,e.ambulatory care nursing
administration and practice standards .these
standards are made to improve the services.
 Structure and organization of ambulatory
care nursing,
 Staffing in ambulatory care
 Competency
 Ambulatory nursing practice
 continuity of care
 ethics and patients rights
 environment
 research
 Quality management.

o Competence.
Competence is the demonstrated knowledge,
skills, and ability to effectively carry out the
requirements of a given role.
Ambulatory care nurses demonstrate
competence in core clinical practice
dimensions, such as client teaching.
They also have competencies that reflect the
unique clinical dimensions of ambulatory care
nursing, such as telephone nursing and that
correspond to the needs of the particular client
populations served and the nursing
interventions commonly required by such
populations.
o Certification ,
Holding certification in a specialty practice
area such as ambulatory care nursing is a way
of demonstrating competence to consumers and
colleagues. To obtain certification, practicing
nurses prepare for and take an examination
that is developed by a panel of experts and
administered by a recognized certification
agency.
o Regulatory compliance.
Ambulatory settings must be licensed in the
state in which they are located. Accreditation
demonstrates compliance with a uniform set of
standard, it allows comparisons with a uniform
set of standards .it allows comparisons with
other organizations and enhances the
organizations competitive edge. E.g.. JCAHO.
o Multi state licensure.
Multi state licensure is an issue that emerged
because there are increasing numbers of
national health care systems and Telehealth
nursing practice is more common and people
are more mobile in seeking care.
The legal authority for practice is a concern for
any professional nurse who provides care for
people located in a state in which the nurse is
not licensed.
Nurses who mist be concerned about
multi state licensure are
 Nurses working in integrated delivery systems
and regional referral health care systems in
which people come from other states
 Flight nurses and
 Tele health practice nurse.
 Nursing responsibilities.

 Clinical Nursing Role

 Patient Education
 Advocacy (compassion, caring, emotional
support)
 Care Management
 Assess, Screen, Triage
 Telephone Practice
 Collaboration/Resource Identification and
Referral
 Clinical Procedures
 Independent/Interdependent/Dependent
Primary, Secondary, and Tertiary Prevention
 Communication/Documentation
 Outcome Management
 Protocol Development/Usage
Organization/Systems Role
 Practice/Office Support
 Healthcare Fiscal Mgmt. (reimbursement and
coding)
 Collaboration/Conflict Mgmt. Informatics
Context of Care Delivery/Models
 Care of the Caregiver
Priority Management/Delegation/Supervision
 Ambulatory Culture/Cross Cultural
Competencies
 Ongoing Political/Entrepreneurial Skills
Structuring Customer-focused Systems
Workplace Regulatory Compliance (EEOC,
OSHA)
 Advocacy Inter-organizational and in
Community
 Legal Issues
 Professional Role
 Evidence-based Practice
 Leadership Inquiry and Research Utilization
 Clinical Quality Improvement
 Staff Development
 Regulatory Compliance (risk management)
 Provider Self-Care
3. Acute care and critical care.
a. Acute care. An institution with primary function of
providing diagnostic and therapeutic client services for a variety of
medical conditions, both surgical and non surgical.
 Types of hospitals ;

 Government sponsored hospitals

These hospitals receive local, state, or federal
government support examples include the army, navy,
public health service .state supported facilities include
psychiatric hospitals, state university hospitals, and
state prison hospitals. Locally supported institutions
include country and city hospitals.
 Voluntary or non profit agencies
These are the hospitals designed to meet the health
care needs of the general public.
 Profit hospitals
Like voluntary hospitals they also serve general public
but with goal of profit and business.
 Magnet hospitals.
Such a designation is given to hospitals that have a
reputation for providing excellent nursing care and
for having good medical outcomes .these hospitals
often provide medical services for complex problems
that require a team of health care providers, which
would be too expensive to replicate in multiple sites.
 Client admission to a hospital.
 Direct
A client is seen in a physician’s office, and it is
determined that the client needs nursing care and
specialized monitoring.
 Emergency
A client is seen in emergency department and it is
determined that client needs surgery, nursing care, and
specialized monitoring .the disease that has been
diagnosed is considered likely cannot be managed on an
outpatient or self care basis.
 Scheduled
A client has elected to undergo surgery or special
diagnostic testing that requires specialized monitoring
nursing care during recovery.
 Post acute care.
Post acute care is one of the fastest growing segments of
health care. It is called in different terms like progressive,
transitional, step-down units. It is designed to fill the gap
between acute and long term or home care.
All the clients will experience post acute care. If the client
can do his own care at home, patient will be discharged.
E.g. open heart surgery patients.

 Nurses role in hospitals

Nursing is a service provided both to individual clients
and to aggregates of people. E.g. families, groups. Nurses
in he acute care hospital setting are providers of direct
care, educators, researchers, and managers.

 Provider of direct care.

Most people are familiar with nurses as providers of
direct care. Nurses assess, care for, educate, and
comfort clients. Nurses provide direct care in all
settings and along all dimensions of the health –
illness continuum, from health promotion to critical
care and death.

 Educator
Professional nurses provide formal and informal
education to their clients, individually and in
groups. Informal education goes on almost
continually; clients are taught about medications
while the medications are being administered, about
the importance of assessment parameters when
wound care is being done, and so on.
Formal education is usually provided to groups of
clients and their families. Advantages of formal
education are that the client is usually prepared for
learning .some nurse who are specialized in
particular field will help in rehabilitation. e.g.
rehabilitation.
 Researcher.
Most acute care hospitals have research
committees that select areas for study .hospital
nurses can identify topics to research , help develop
and implement a study , collect data , and present
and utilize the study findings .e.g. skin care
protocol, wound dressing .
 Manager.
Term manager in this discussion means the
person who coordinates human and material
resources in providing care to clients. It includes
 The client
 The nurse
 Family
 Professional colleagues
 Support groups
 Resource groups

B.Critical care.
Critical care nursing is the field of nursing with a focus
on the care of the critically ill or unstable patients. Critical
care nurses can be found working in a wide variety of
environments and specialties, such as emergency departments
and the intensive care units

 Need for the admission.

The most common cause for the admission is for intensive
monitoring and life supportive care.

Common condition necessitating ICU admissions.

 Respiratory difficulties impairing the client’s ability to

ventilate and oxygenate .e.g., pneumonia, respiratory
distress .in this case ventilators will be necessary for
the patients.
 Circulatory problems such as hypotension .clients may
have had a MI in this conditions clients will be placed
on cardiac monitor.
 Neurological changes, such as loss of consciousness or
changes in mental status. e.g. head injury, brain
surgery.
 Life threatening infection or risk of infection such as
burn wounds or sepsis. Requires intensive care to
control blood pressure and maintain perfusion of the
heart, brain, lungs, and kidney.

 Role of nurse.
 Critical care nurses concentrate specifically on the care
of clients with life threatening problems. Interventions
for these clients must be adjusted continually based on
constant monitoring of their response to treatment.
 Continuous nursing vigilance is the key to this nursing
specialty and can make a significant difference in
salient outcomes.
 A critical care nurse does use the latest machines to
provide highly technical care.
 She should create environment that promotes healing.
 She should also provide complementary therapies such
as music therapy, prayer, talking.
 While planning this type of care nurse should also
include family members.
 Critical nurse must constantly keep up with the latest
information and become proficient with more complex
technologies and treatments.
 She should acts as bed side nurse, critical care
educator, case manager, unit manager, clinical nurse
specialist and nurse practioners.
5. Long term care.
Long term care refers to the care of patients for a time
period greater than 30 days .long term care may be required
for individuals who are severely developmentally disabled,
are mentally impaired, pr have physical deficits requiring
continuous medical or nursing management, such as those
who are ventilator dependent and those with Alzheimer’s
diseases.

Long term care facilities include

 Skilled nursing facilities :
Skilled nursing facilities provide care for patients who
require 24 hour nursing supervision, many of whom are
confined to bed for some portion of the day or are
incontinent.
And also offers a transitional level of post acute care in
which the patient requires specified nursing skills and
therapeutic support .it also provides an emphasis on
rehabilitative therapies for convalescing patients. These
patients may be too weak or ill to tolerate rapid
rehabilitation .some patients are terminally ill or disabled to
the degree that continuous nursing support is required.
 Intermediate care facilities
An intermediate care facility provides convalescent care and
regular medical, nursing, social, and rehabilitative services
in addition to room and board for people not capable of
independent living.
Residents in these facilities require less intensive nursing
care than that provided by skilled nursing facilities
.intermediate care can be temporary care for individuals
recovering from an acute illness or injury and often for
those who have been discharged from the hospital.
Common goals of these facilities are to assess what
individuals are capable of doing and to help them achieve
their potential by teaching and training them to achieve
maximum independence.

 Retirement communities
Some long term care settings may include the entire
spectrum of care. Residents may reside in a continuing
care retirement community .which is a blend of several
options, including housing complex, activity center, and
health care system. CCRCs differ from other retirement
options by providing a continuum of housing, services,
and health care, there is a written agreement or contract
between the resident and the CCRC that is written
agreement or contract between the resident and the
CCRC that is generally intended to last the resident’s
lifetime or for a specific period of time.

 Residential care facilities

Residential care facilities may be referred to as supervisory
care homes or assisted living arrangements. both settings
are generally licensed by the state to ensure that quality
living ,safety ,and health care standards are met .residents
generally must be able to care for themselves and move
about without the help ;of another person .residents often
live in these care homes to obtain additional assistance for
their activities of daily living, such as grooming and meal
preparation or supervision with their medications., any of
these facilities also have a skilled nursing facility .this
enables residents who temporarily need skilled nursing care
to receive it until they can return to their own residence.

 Special care units.

Some individuals with cognitive impairments may require
special assistance in their long term care with increasing
numbers of residents. With increasing numbers of residents
with Alzheimer’s disease and other forms of dementia m
special care units have been developed to address the
unique needs of these individuals.
 Nurses role.
 Assessment
the facility is required to assess residents
within the first 14 days of admission and at least
annually there is a change in their status .the
minimum data set is the tool on which the
assessesment is to be documented, it is a minimum
assessment .here important pieces of information
are not captured , such as the client s self concept ,
spirituality ,sense of purpose , immunity ,stress
management use of alternative therapies, and
attitudes regarding health status and death
.because these are important areas for
consideration in the long term care of residents, you
may want to supplement the ,MDS with additional
assessment data.
 Care planning.
Regulations require that a care plan be written for
each resident within 7 days after completion of the
assessment. The care plan is an interdisciplinary
one, nurses coordinate the input offered by each
discipline and ensure that the plan is written in a
correct, timely manner .even the residents and
family should be involved in development of plan.
Goals and actions that are no longer relevant need
to be revised .all members of the team, particularly
nursing assistants who perform most direct care
activities, must be familiar with the care plan.
 Care giving.
In LTCFs .nurses perform selected roles, such as
administering medications and treatments, in others,
they may be involved in total care activities .during the
pre-employment interview, nurses should review the
job descriptions for their specific positions to ensure
that they have a realistic view of their role.

 Communication.
Since the nurse has regular and close contact with
residents, nursing assistants may be the first and only
caregivers to detect changes in health status .there
fore ,effective channels of communication are crucial
in reporting these findings .and telephone orders
should be taken care when receiving the order from
physician .and should be documented.

 Management .along with these roles she has to

perform management roles also.
 Delegating assignments
 Supervising other staff
 Evaluating performance
 Implementing disciplinary actions
 Completing reports
 Reviewing and auditing records
 Communicating needs to other departments
 Handling complaints
 Ordering supplies
 Communicating with insurers, regulatory
agencies, and other parties.

6. Home health care

Home health care refers to health care delivered in the home
setting .the national association for home care defines home care
as broad spectrum of health care and social services provided in
the home environment to recovering .disabled, or chronically ill
patients.
It includes health maintenance .education, illness prevention,
diagnosis and treatment of disease .palliative care, and
rehabilitation.

 patient care in the home

The most common diagnoses for home care patients are
diabetes mellitus .hypertension .heart failure .stroke
.skin ulcers. Skilled nursing care may include
observation, assessment, management, evaluation,
teaching, administration of medications, tube feedings,
catheter care, etc.
Examples of home health care nursing activities.
 Assessment
 Wound care
 Respiratory care
 Vital signs
 Elimination
 Nutrition
 Rehabilitation
 Medications
 Intravenous therapy
 Pain management
 Selected laboratory studies.
 home health care team
Home health care team includes
 family and patient
 physician
 nurse

 social worker
Assists patients with coping skills, securing
adequate financial resources or housing assistance or
making referrals to social service or volunteer agencies
 occupational therapist
Assist the patient with fine motor coordination,
performance of the activities of daily living, cognitive
perceptual skills, Sensory testing.
 physical therapist ;
References will be given in case of orthopedic
conditions, such as hip or knee surgeries or
neuromuscular deterioration commonly seen with
multiple sclerosis, stroke. Here therapist will
work with patients on strengthening and
endurance, gait training.
 speech therapist
Focus on various speech pathologies for those
who have suffered speech or swallowing
disorders seen in patients with stroke,
laryngectomy.
 home health aide
Assist patients with their personal care needs,
such as bathing, dressing, hair washing.
 pharmacist
Involved in preparation of infusion products,
 respiratory therapist
Assists in oxygen therapy in home setting
 Dietician.
Will help in dietary consultation.
 nurses role
 Home care nurses must have expert organizational
skills, be able to make independent decisions, and
know how to set priority and respond to problems
promptly.
 She must adapt to a variety of circumstances that
challenge their assessment, planning .and intervention
abilities.
 Attributes of home health care nurses include
flexibility, empathy, patient advocacy, and the ability
to function independently in the home setting.
 Nurse must use concise and accurate documentation
to ensure both legal and professional accountability.
 Tele visiting allows the nurse to do triage and provide
advise, counseling, and referral for a patients health
problem using the phone or computers with cameras.
 Home health care nurses must also be knowledgeable
in the adaptive equipment or assistive devices used n
the patient’s home to promote independent
functioning.
 Continuous quality improvement is a mandate for
home health care agencies and nurses.
 Should maintain confidentiality of patient’s .and
should focus on empowering the patients and family to
meet their own needs.

7. Conclusion: AMBULATORY CARE, ACUTE AND CRITICAL CARE, LONG

TERM CARE, HOME HEALTH CARE. is now a days becoming very important role in
maintaining the health status of the different age group and giving lots of choices
for the family for the health benefit.

8. References
 Black mj ,hawks jh. medical surgical nursing,clinical management for
positive outcomes.7th ed.missouri:saunders;2005.p.133-88.
 Lewis,heitkemper,dirksen.medical surgical nursing,assessment and
management of clinical problems.6th ed.missouri:mosby;2004.p.85-91.
 Brunner , Suddarth’s. Textbook of Medical-
Surgical Nursing.10th ed.lww;2004.p.45-51.
 Ambulatory care –wikipedia the free encyclopedia
.mar 23 ,2009;available from:
URL:en.wikipedia .org/wiki/ambulatory_care.
 Longterm care –wikepedia the free encyclopedia .
2009;available from:
URL:en.wikipedia.org/wiki/longterm_care.
 Home health care-wikepedia the free
encyclopedia.2009;available from:
URL:en.wikipedia.org/wiki/homehealth_care.

Journal reference.
Tejal K. Gandhi, M.D., M.P.H., Saul N. Weingart, M.D.,
Ph.D., Joshua Borus, B.A., Andrew C. Seger, R.Ph., Josh
Peterson, M.D., Elisabeth Burdick, M.S., Diane L. Seger,
R.Ph., Kirstin Shu, B.A., Frank Federico, R.Ph., Lucian L.
Leape, M.D., and David W. Bates, M.D.Adverse Drug
Events in Ambulatory Care, Volume 348:p.1556-1564.

 Adverse events related to drugs are common in primary care, and

many are preventable or ameliorable. Monitoring for and acting on
symptoms are important. Improving communication between
outpatients and providers may help prevent adverse events related to
drugs.
THE OXFORD COLLEGE OF NURSING.

SUBJECT: MEDICAL SURGICAL NURSING.

TOPIC: AMBULATORY CARE, ACUTE AND CRITICAL

CARE, LONG TERM CARE, HOME HEALTH CARE.

SUBMITTED TO.
MR.BABU .R
PROFFESER (MSN)
THE OXFORD COLLEGE OF NURSING.

SUBMITTED BY.
SANDESH.K.S
1ST YEAR MSC NSG.
THE OXFORD COLLEGE OF NURSING.

SUBMITTED ON. 18/07/2009.