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Key Topics
Assessment is one of the major roles of the registered nurse and is the first step in the nursing process to assist in planning and to facilitate mutually established goals and evaluate outcomes. In reality the nurse is continually assessing and re-assessing the patient throughout the continuity of care.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice
? Identify 3 specific nursing assessments that you would conduct as a priority for Jim’s nursing care that you will undertake on Jim’s admission to your ward.
AND
For each assessment you have identified explain:
? Why the assessment is relevant to Jim’s care.
? What consequences may occur if this assessment is not completed accurately?
(300 words, 10 marks)
Task 2: Care planning
Based solely on the handover you have received and using the template provided, develop a care plan for five (5) nursing problems related to fundamentals of care from Week 1 learning materials.The first 3 nursing problems have been identified and are included in the template. These nursing problems cannot be changed and a care plan needs to be developed for each. Your task is to identify another 2 priority nursing problems related to fundamental care needs and for each of the 5 nursing problems identify:
Based solely on the handover you have received and using the template provided, develop a care plan for five (5) nursing problems related to fundamentals of care from Week 1 learning materials.The first 3 nursing problems have been identified and are included in the template. These nursing problems cannot be changed and a care plan needs to be developed for each. Your task is to identify another 2 priority nursing problems related to fundamental care needs and for each of the 5 nursing problems identify:
? The underlying cause or what the nursing problem is related to
? Goal of care
? Specific bedside nursing interventions you will do
? The rationales for your nursing interventions and actions
? Indicators that your plan is working
Task 3: Medication management
Three important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, understanding the nursing responsibilities and how to monitor the patient to ensure they are responding to prescribed medications as they should.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice,
? Goal of care
? Specific bedside nursing interventions you will do
? The rationales for your nursing interventions and actions
? Indicators that your plan is working
Task 3: Medication management
Three important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, understanding the nursing responsibilities and how to monitor the patient to ensure they are responding to prescribed medications as they should.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice,
? Briefly explain why Jim has been prescribed:
o Oseltamivir 75mg orally bd
o Paracetamol 4/24 orally prn
o Fluvax IM stat dose
AND
? Identify and explain
o The specific nursing responsibilities associated with administering each medication
o How you will monitor Jim for expected, side and adverse effects of each medication.
Task 4: Patient teaching
You recognise part of your nursing role is to provide Jim with education on:
o Preventing and controlling the incidence and spread of influenza
o Reducing the modifiable risk factors for hypertension
o Health promotion and minimising risk of hospitalisation
Select one (1) of the topics above and, in grammatically correct sentences and topic paragraphs,
? Identify the specific information you will need to explain to Jim about the topic
AND
? Explain
o Why the topic is an important aspect of Jim’s care
o How you will ensure that Jim knows and understands why it is important and, if appropriate to the topic, what he needs to do
o Oseltamivir 75mg orally bd
o Paracetamol 4/24 orally prn
o Fluvax IM stat dose
AND
? Identify and explain
o The specific nursing responsibilities associated with administering each medication
o How you will monitor Jim for expected, side and adverse effects of each medication.
Task 4: Patient teaching
You recognise part of your nursing role is to provide Jim with education on:
o Preventing and controlling the incidence and spread of influenza
o Reducing the modifiable risk factors for hypertension
o Health promotion and minimising risk of hospitalisation
Select one (1) of the topics above and, in grammatically correct sentences and topic paragraphs,
? Identify the specific information you will need to explain to Jim about the topic
AND
? Explain
o Why the topic is an important aspect of Jim’s care
o How you will ensure that Jim knows and understands why it is important and, if appropriate to the topic, what he needs to do
MEDICAL/ SURGICAL NURSING
INTRODUCTION
The present study has been emphasizing on Jim who is a 58 year old homeless indigenous is currently admitted in Emergency Department because he has the symptoms of dyspnea, fatigue, headache and malaise. Considering his medical examination, the study has included discussion about patient assessment wherein 3 specific nursing assessments are identified as priority for Jim’s care.
TASK 1
Assessment is regarded as the first part of the nursing process in which detailed information about the patient is being collected. After assessment, nursing care plan is being formulated with holistic nature. It also includes in-depth analysis about history of patient’s problems and type of services rendered (Kamienski & Keogh, 2017). In the present case, proper examination is required regarding patient’s problems by looking at the ways of resolving diverse problems. Since, Jim has shown numerous symptoms; therefore it is crucial for the nurse to identify all the problems to deliver proper care to the patient. Lack of assessment in nursing care can create numerous problems and it can affect the provision of proper diagnosis. The medication process shall not be started prior conducting suitable assessment. As per the present case, it is essential for the nurses to focus on nursing priorities so that on such basis, proper care and treatment can be provided. The three major priorities are mentioned as follows:
• Risk of imbalanced fluid volume
• Self care deficit
• Influenza A
• Self care deficit
• Influenza A
When Jim is admitted to the ward, he has shown symptoms of preliminary Influenza and has also commenced an oseltamivir which is the results of his flu swab. His symptoms occurred 1 day ago and he continuously getting worse. While examining the patient problem, it is being ascertained that Jim was found to be febrile with a clear and nasal discharge, shortness of breath and muscle soreness (Alligood, 2017). Considering, his previous medical condition, it is analyzed that Jim had asymptomatic hypertension; however currently he is not prescribed antihypertensive medication. Nurses has also diagnosed that Jim does not consume any such prescribed medication; thus no medicine is yet given to him. At the same time, he is also allergic to chickens; but has not shown any sort of drug allergies. Jim has also stated that he used to smoke but currently is not smoking as he cannot afford it.
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Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immuno compromised patients in the hospital setting are at higher risk of contracting disease resulting in adverse events (Butcher et al. 2018). Since, it is a viral infection; therefore it can affect the respiratory system and can cause vomiting and diarrhea. It travels through air droplets especially when having infection such as coughs, sneezes and talks. Jim has continuous nasal discharge, shortness of breath and muscle soreness; therefore suitable treatment is required to be given to Jim.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To prevent and control the spread of influenza within the healthcare facility and the community.
As per the prescription, Amantadine or Zanamivir can be provided to Jim twice a day. However, Jim should be advised for regular mouth wash or warm saline gargles which can ease sore throat. Nurses will also administer intake of fluids which will be provided to Jim. The treatment will be effective for Jim since he will be able to improve the medical conditions as early as possible. There will be proper monitoring of the patient’s conditions so as to analyse the effectiveness of treatment.
Nursing problem: Self care deficit
Underlying cause or reason:This is an impaired ability to perform different tasks of a day. Self care refers to those activities which an individual perform for the purpose of promoting and maintaining personal well-being (Jacob, Duffield & Jacob, 2017). As per the case, it has been identified that Jim is an irresponsible man and he does not take any sort of medication which is being prescribed to him in accordance to his medical condition.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To encourage Jim to take care of his health by focusing on all the methods that is being suggested by the nurses.
As per the problem, it is essential for the nurse to show the way of proper care to Jim regarding oral and physical health services. Nurses should also direct Jim to take the prescribed medications so that he can overcome his health conditions. It is crucial for Jim to have appropriate knowledge about oral hygiene since he is at risk of Influenza A virus. Nurses should have proper eye on Jim’s activities so as to analyse his consideration on given things. Hence, proper administration is also required in all domains.
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: This is the state of decreased intravascular, interstitial and intracellular fluid. This is also known as the situation of dehydration and water loss without having any change in the sodium (Johny et al. 2017). In this context, the intake of fluid is less in Jim as compared to the fluid output. It happens in Jim because water and electrolytes are lost as they exist in normal body fluids. There should be appropriate management for fluid intake as long term imbalance may cause vascular, cellular or intracellular dehydration.
Goal of care Nursing interventions/actions
Rationale
Indicators your plan is working ,The main of this care is to balance the intake and outtake of fluids. The nurse should instruct the client or other necessary self intervention like routinely measuring the weight to analyse own health dimensions. At the same time, nurse should also keep a record about urine elimination, fecalelimination, fluid intake and weight. There should be appropriate consideration regarding fluid management. This is essential for the purpose of protecting the patient from other health problems and issues. Record will be kept regarding urine elimination and regular check up will be made accordingly.
Nursing problem: Asymptomatic hypertension
Underlying cause or reason: This is the condition wherein Jim has presented severely elevated blood pressure. This is different with that to hypertensive emergency; however the patient who is asymptomatic has poor controlled hypertension (Kamienski & Keogh, 2017). Thus, along with this, Jim can also associate with cardiovascular risk profile. In this condition, Jim needs to have aggressive evaluation and treatment to resolve the problem accordingly.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To reduce the risk of cardiovascular disease, stroke, renal disease and death. Immediate diagnostic testing is essential in terms of short-term management and this is also useful in controlling blood pressure level. This can be best achieved through adjusting with antihypertensive therapy. However, in this case, aggressive lowering of blood pressure should be avoided by giving parenteral medications This sort of treatment is essential so that chances of occurring other risks can be reduced. There will be proper checking of blood pressure level on continuous basis. This is essential for suitable treatment.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To reduce the risk of cardiovascular disease, stroke, renal disease and death. Immediate diagnostic testing is essential in terms of short-term management and this is also useful in controlling blood pressure level. This can be best achieved through adjusting with antihypertensive therapy. However, in this case, aggressive lowering of blood pressure should be avoided by giving parenteral medications This sort of treatment is essential so that chances of occurring other risks can be reduced. There will be proper checking of blood pressure level on continuous basis. This is essential for suitable treatment.
Nursing problem: Musculoskeletal
Underlying cause or reason: This sort of problem is most often caused by any type of injury to the bones, joints, muscles, tendons ligaments or nerves. Typically, it is caused by jerking movements, fractures and sprains. Since, Jim has no specific place to reside; therefore he does not have any sort of rest for his body (Melin?Johansson, Palmqvist & Rönnberg, 2017). Hence, it can be said that due to prolonged immobilisation, the chances of risk can increase more.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To ensure that Jim is having joint movements by focusing on different therapeutical aspects. It can be treated with specific therapies and also through facilitating direct movement of joints. Along with this, medications can also be provided to enhance body’s level of serotonin and norepinephrine. The provided medication will also assist Jim, to sleep properly and it can also result in speedy recovery. Nurses will ensure if Jim is continuously having movements of joints.
Underlying cause or reason: This sort of problem is most often caused by any type of injury to the bones, joints, muscles, tendons ligaments or nerves. Typically, it is caused by jerking movements, fractures and sprains. Since, Jim has no specific place to reside; therefore he does not have any sort of rest for his body (Melin?Johansson, Palmqvist & Rönnberg, 2017). Hence, it can be said that due to prolonged immobilisation, the chances of risk can increase more.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To ensure that Jim is having joint movements by focusing on different therapeutical aspects. It can be treated with specific therapies and also through facilitating direct movement of joints. Along with this, medications can also be provided to enhance body’s level of serotonin and norepinephrine. The provided medication will also assist Jim, to sleep properly and it can also result in speedy recovery. Nurses will ensure if Jim is continuously having movements of joints.
TASK 3
At the time of proper medication to Jim, it is crucial for the nurse to administer the effect of medication. The dose of medication should be checked appropriately so that the chances of side effects can be reduced. Nurses who are dealing with Jim needs to take care of specific things while prescribing the medicines (Morton et al. 2017). Regular monitoring and assessment is essential because Jim does not take medicines which are prescribed yet; therefore nurses must be stern for this case. Since, Jim has shown potential risks for Influenza A; therefore proper medicines should be provided accordingly else the problem may be hazardous for Jim in different dimensions. The virus can spread to other people also which could harm patients as well as staff members; thus proper care ought to be given in Jim’s case. Health condition of Jim may get improved in the case of giving him appropriate medicines (Rabelo?Silva et al. 2017).
• Oseltamivir 75mg orally bd has been provided to Jim during Influenza epidemic. It is also called as influenza neuraminidase inhibitor which will prevent the flu. During bedside, the medicine will be provided directly by the nurses because Jim is careless is taking medicines.
• Paracetamol 4/24 has also been provided to Jim so as to reduce the problem of headache and other analgesic effects. The medicine will also help Jim to control the nasal cavity by regular consumption of the medication. Here, nurses need to check if proper dosage is being given to Jim as per the prescription. This way, there will be proper medication administration for Jim’s case (Rahmani et al. 2017).
• Fluvax IM stat dose is also given to Jim for the purpose of mitigating the impact of virus on other body parts. The virus may impact other body parts and organs; therefore proper medication is essential in this respect. This is also crucial for the purpose of protecting Jim from all sorts of co-morbid harms and injuries.
• Oseltamivir 75mg orally bd has been provided to Jim during Influenza epidemic. It is also called as influenza neuraminidase inhibitor which will prevent the flu. During bedside, the medicine will be provided directly by the nurses because Jim is careless is taking medicines.
• Paracetamol 4/24 has also been provided to Jim so as to reduce the problem of headache and other analgesic effects. The medicine will also help Jim to control the nasal cavity by regular consumption of the medication. Here, nurses need to check if proper dosage is being given to Jim as per the prescription. This way, there will be proper medication administration for Jim’s case (Rahmani et al. 2017).
• Fluvax IM stat dose is also given to Jim for the purpose of mitigating the impact of virus on other body parts. The virus may impact other body parts and organs; therefore proper medication is essential in this respect. This is also crucial for the purpose of protecting Jim from all sorts of co-morbid harms and injuries.
TASK 4
With the help of reviewing case scenario of Jim, it was stated that nurse should impart necessary education to Jim so that he may engage in activities that support in maintaining his health and well-being (Rajabpoor et al. 2018). Through reviewing the medical history of Jim it was stated that he was suffering from asymptomatic hypertension so that he may engage in reducing the modifiable risk factors for hypertension. Thus, imparting this education to Jim results in overcoming the complications that would negatively affect the overall body.
However, the selected topic of reducing risk factors for hypertension is an important aspect of Jim’s care as increasing and uncontrollable hypertension results in ischemic heart disease that lead to patient die with the stroke. Along with this, educating on the topic also results in changing their lifestyle that can aid Jim in controlling their high blood pressure that further diminish the danger of life-threatening difficulties (Santos, Ramos & Fonseca, 2017). After imparting the education or knowledge on the important topic nurse will engage in diagnose the level of blood pressure in Jim’s body. In the situation if there is increase in the blood pressure rate then in such case it will be identified that Jim has not followed accordant with the prescribed medication and treatment.
However, the selected topic of reducing risk factors for hypertension is an important aspect of Jim’s care as increasing and uncontrollable hypertension results in ischemic heart disease that lead to patient die with the stroke. Along with this, educating on the topic also results in changing their lifestyle that can aid Jim in controlling their high blood pressure that further diminish the danger of life-threatening difficulties (Santos, Ramos & Fonseca, 2017). After imparting the education or knowledge on the important topic nurse will engage in diagnose the level of blood pressure in Jim’s body. In the situation if there is increase in the blood pressure rate then in such case it will be identified that Jim has not followed accordant with the prescribed medication and treatment.
TASK 5
After Jim has been tested positive with the Influenza A it results in taking continued medication that decreases the symptoms of Influenza. Thus, he was scheduled to be discharged from the hospital as he has completed his antiviral medication course. On the next morning nurse has reviewed the Jim and found that he seems to be unsettled than the usual day his vital sign observation were as follows-
Vital signs
Temperature 39.6 C
Heart rate 125 beats per min
Respiratory rate 24 resps per min
Blood pressure 124/79 mmHg
O2 saturations 86% on room air
With the help of reviewing vital sign it was identified that Jim temperature was above the normal temperature that results in feeling cold to Jim (Ueda, Mizuguchi, Sasaki & Yokoyama, 2017). On the other hand, Respiratory rate of Jim was also high that is 24 resps per min that lead to intake more air. In this situation nurse actions and intervention must focuses on allowing oxygen mask to Jim so that it normal the respiratory rate.
To impart effective services and nursing care to Jim, nurses are required to implement the legal requirement that engages in imparting effectively and concisely transferring of the relevant information, actions and outcomes of patient care through reviewing the health of the patient. With the help of communicating relevant information, it results in-
• Identifying the health and nursing care plan of Jim
• After that, it focuses on analysing the situation of Jim that is he has improved his health or not (Urden, Stacy & Lough, 2017)
• It also engages in assessing the background of the patient to impart proper care and treatment
For the continuation of nursing care of Jim it has been stated the nurse should also engage in imparting person centered care. With the help of this they empower patient to take health services and treatment accordant with their requirement.
Vital signs
Temperature 39.6 C
Heart rate 125 beats per min
Respiratory rate 24 resps per min
Blood pressure 124/79 mmHg
O2 saturations 86% on room air
With the help of reviewing vital sign it was identified that Jim temperature was above the normal temperature that results in feeling cold to Jim (Ueda, Mizuguchi, Sasaki & Yokoyama, 2017). On the other hand, Respiratory rate of Jim was also high that is 24 resps per min that lead to intake more air. In this situation nurse actions and intervention must focuses on allowing oxygen mask to Jim so that it normal the respiratory rate.
To impart effective services and nursing care to Jim, nurses are required to implement the legal requirement that engages in imparting effectively and concisely transferring of the relevant information, actions and outcomes of patient care through reviewing the health of the patient. With the help of communicating relevant information, it results in-
• Identifying the health and nursing care plan of Jim
• After that, it focuses on analysing the situation of Jim that is he has improved his health or not (Urden, Stacy & Lough, 2017)
• It also engages in assessing the background of the patient to impart proper care and treatment
For the continuation of nursing care of Jim it has been stated the nurse should also engage in imparting person centered care. With the help of this they empower patient to take health services and treatment accordant with their requirement.
CONCLUSION
In the next section, researcher has stated about care planning needs of Jim; hence for that nursing care intervention is also specified. Furthermore, researcher has also stated about proper medication process which is being provided to Jim. Lastly, researcher has also described the requirement of person- centered care approach.
REFERENCES
Alligood, M. R. (2017). Nursing Theorists and Their Work-E-Book. Elsevier Health Sciences.
Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. (2018). Nursing Interventions classification (NIC)-E-Book. Elsevier Health Sciences.
Jacob, E., Duffield, C., & Jacob, D. (2017). A protocol for the development of a critical thinking assessment tool for nurses using a Delphi technique. Journal of advanced nursing, 73(8), 1982-1988.
Johny, S. A., Moly, K. T., Sreedevi, P. A., & Nair, R. R. (2017). Effectiveness of Nursing Process based Clinical Practice Guideline on Quality of Nursing Care among Post CABG Patients. International Journal of Nursing Education, 9(2), 120-126.
Kamienski, M., & Keogh, J. (2017). Pharmacology Demystified. 2e. McGraw Hill Professional.
Melin?Johansson, C., Palmqvist, R., & Rönnberg, L. (2017). Clinical intuition in the nursing process and decision?making–A mixed studies review. Journal of clinical nursing.
Morton, P. G., Fontaine, D., Hudak, C. M., & Gallo, B. M. (2017). Critical care nursing: a holistic approach (p. 1056). Lippincott Williams & Wilkins.
Rabelo?Silva, E. R., Dantas Cavalcanti, A. C., Ramos Goulart Caldas, M. C., Lucena, A. D. F., Almeida, M. D. A., Linch, G. F. D. C., ... & Müller?Staub, M. (2017). Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA?International (NANDA?I) and Nursing Interventions Classification (NIC). Journal of clinical nursing, 26(3-4), 379-387.
Rahmani, M., Davarpanah, M., Naseri, M., Hamedpour, H., Hamedpour, R. N., & Mahmudbeik, B. (2017). The Effect of Nursing Process Implementation using “Accessible Care Cards” Method on Satisfaction Rate of Nurses, Patients and Parents of Inpatient Children of Care Manner. INTERNATIONAL JOURNAL OF MEDICAL RESEARCH & HEALTH SCIENCES, 6(9), 121-130.
Rajabpoor, M., Zarifnejad, G. H., Mohsenizadeh, S. M., Mazloum, S. R., Pourghaznein, T., Mashmoul, A., & Mohammad, A. (2018). Barriers to the Implementation of Nursing Process From the Viewpoint of Faculty Members, Nursing Managers, Nurses, and Nursing Students. Journal of Holistic Nursing And Midwifery, 28(2), 137-142.
Santos, B., Ramos, A., & Fonseca, C. (2017). Training to practice: Importance of Self-Care Theory in Nursing Process for improving care.
Ueda, I., Mizuguchi, W., Sasaki, M., & Yokoyama, M. (2017). Study on the Content Validity of the Essential Assessment Items Required for Visiting Nurses to Service Users in Japan. International Journal of Studies in Nursing, 2(1), 8.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2017). Critical Care Nursing-E-Book: Diagnosis and Management. Elsevier Health Sciences.
Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. (2018). Nursing Interventions classification (NIC)-E-Book. Elsevier Health Sciences.
Jacob, E., Duffield, C., & Jacob, D. (2017). A protocol for the development of a critical thinking assessment tool for nurses using a Delphi technique. Journal of advanced nursing, 73(8), 1982-1988.
Johny, S. A., Moly, K. T., Sreedevi, P. A., & Nair, R. R. (2017). Effectiveness of Nursing Process based Clinical Practice Guideline on Quality of Nursing Care among Post CABG Patients. International Journal of Nursing Education, 9(2), 120-126.
Kamienski, M., & Keogh, J. (2017). Pharmacology Demystified. 2e. McGraw Hill Professional.
Melin?Johansson, C., Palmqvist, R., & Rönnberg, L. (2017). Clinical intuition in the nursing process and decision?making–A mixed studies review. Journal of clinical nursing.
Morton, P. G., Fontaine, D., Hudak, C. M., & Gallo, B. M. (2017). Critical care nursing: a holistic approach (p. 1056). Lippincott Williams & Wilkins.
Rabelo?Silva, E. R., Dantas Cavalcanti, A. C., Ramos Goulart Caldas, M. C., Lucena, A. D. F., Almeida, M. D. A., Linch, G. F. D. C., ... & Müller?Staub, M. (2017). Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA?International (NANDA?I) and Nursing Interventions Classification (NIC). Journal of clinical nursing, 26(3-4), 379-387.
Rahmani, M., Davarpanah, M., Naseri, M., Hamedpour, H., Hamedpour, R. N., & Mahmudbeik, B. (2017). The Effect of Nursing Process Implementation using “Accessible Care Cards” Method on Satisfaction Rate of Nurses, Patients and Parents of Inpatient Children of Care Manner. INTERNATIONAL JOURNAL OF MEDICAL RESEARCH & HEALTH SCIENCES, 6(9), 121-130.
Rajabpoor, M., Zarifnejad, G. H., Mohsenizadeh, S. M., Mazloum, S. R., Pourghaznein, T., Mashmoul, A., & Mohammad, A. (2018). Barriers to the Implementation of Nursing Process From the Viewpoint of Faculty Members, Nursing Managers, Nurses, and Nursing Students. Journal of Holistic Nursing And Midwifery, 28(2), 137-142.
Santos, B., Ramos, A., & Fonseca, C. (2017). Training to practice: Importance of Self-Care Theory in Nursing Process for improving care.
Ueda, I., Mizuguchi, W., Sasaki, M., & Yokoyama, M. (2017). Study on the Content Validity of the Essential Assessment Items Required for Visiting Nurses to Service Users in Japan. International Journal of Studies in Nursing, 2(1), 8.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2017). Critical Care Nursing-E-Book: Diagnosis and Management. Elsevier Health Sciences.
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