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UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSING31375351270Student: Emma JagasiaMSI & MSII Patient Assessment Tool .Assignment Date: 1/25/15 ± 1 PATIENT INFORMATION Agency: FHTPatient Initials: E.C. Age: 60Admission Date: 1/25/15Gender: Female Marital Status: MarriedPrimary Medical Diagnosis Primary Language: English COPD ExacerbationLevel of Education: BAOther Medical Diagnoses: (new on this admission)Occupation (if retired, what from?): retired school teacherMRSA, VRENumber/ages children/siblings:no children, no siblings Served/Veteran: NOIf yes: Ever deployed? Yes or NoCode Status: Full CodeLiving Arrangements: Condo with Husband Advanced Directives: yesIf no, do they want to fill them out?Surgery Date: Procedure:Culture/ Ethnicity /Nationality: Caucasian N/aReligion: Baptist Type of Insurance: Medicare± 1 CHIEF COMPLAINT:“I couldn't catch my breath and the diarrhea wouldn't stop!”± 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay)This is 60 year old patient with multiple medical problems who came to ER with complaint of shortness of breath for three days with a nonproductive cough. She was also having diarrhea since she had revision surgery of her gastric bypass which was done last year. She was having loose stool almost everyday and she felt like she was dehydrated. She also had generalized weakness. She was admitted for COPD exacerbation also hypokalemia from diarrhea. ± 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of diseaseDate Operation or IllnessThe chart showed no dates and the patient could not recall them GERDCOPDhypothyroidism anemia anxietydepressionCHFoveractive bladderHTNhypoxemiahyperlipidemiaA-fibhypokalemia2/21/13Gastric stapling. hernia repair2010spine surgeryRight knee replacementcarpel tunnel surgeryesophagogastroduodenoscopy ± 2 FAMILY MEDICAL HISTORYAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble(angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFather87renal failureXXXXMother80XBrotherSisterrelationshiprelationshiprelationshipComments: Include age of onset± 1 immunization History (May state “U” for unknown, except for Tetanus, Flu, and Pna)YesNoRoutine childhood vaccinationsRoutine adult vaccinations for military or federal serviceXAdult Diphtheria (Date)X 2013Adult Tetanus (Date) Is within 10 years?X 2010Influenza (flu) (Date) Is within 1 years?X October 2014Pneumococcal (pneumonia) (Date) Is within 5 years?XHave you had any other vaccines given for international travel or occupational purposes? Please ListXIf yes: give date, can state “U” for the patient not knowing date received± 1 ALLERGIES OR ADVERSE REACTIONSNAME of Causative AgentType of Reaction (describe explicitly)MedicationsSulfa drugsthroat itching, rashOther (food, tape, latex, dye, etc.)strawberriesrash, itching ± 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or treatment)COPD or Chronic obstructive pulmonary disease, encompasses both chronic bronchitis and emphysema. Chronic bronchitis is the presence of a chronic productive cough for over 3 months and emphysema is the enlargement of air spaces and destruction of the walls. These two disease combined lead to extreme dyspnea and activity intolerance. Patients with COPD usually present with wheezing, barreled chest, hyper resonance on percussion, coarse crackles, and tachypnea. Diagnosis is made by the use of spirometry, high resolution CT scan, arterial blood gas findings, chest radiographs. There is no cure for COPD; however, it can be managed. If the patient is a smoker, smoking cessation is at the top of the intervention list. Depending on what stage of the disease the patient is at, he or she can be placed on a short acting bronchodilator, long acting bronchodilator, inhaled corticosteriods, and/or long term oxygen therapy. Proper education is essential for these patients to prevent the event of an exacerbation. ± 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]Name albuterol (Proventil)ConcentrationDosage Amount 2 puffsRoute inhaltionFrequency Q6Pharmaceutical class Bronchodilator BothIndication COPDAdverse/ Side effects pounding heart beat, cough, difficultly breathing, redness of the skinNursing considerations/ Patient Teaching patients may become tachycardic after inhaling Name enoxaparin (Lovenox)ConcentrationDosage Amount 40 mgRoute INJFrequency dailyPharmaceutical class Low molecular weight heparinHospitalIndication prophalaxis for DVTAdverse/ Side effects bleeding, dizziness, headache, bruisingNursing considerations/ Patient Teaching Do not rub injection spotName levofloxacin (Levaquin)ConcentrationDosage Amount 750 mgRoute IVFrequency BIDPharmaceutical class FluroquinolonesHospitalIndication bacterial infection Adverse/ Side effects diarrhea, skin each, fever, abdominal rashNursing considerations/ Patient monitor for rhabdomyolysisName levothyroxine (Levothroid)ConcentrationDosage Amount 12.5 mcgRoute POFrequency dailyPharmaceutical class replacement thyroid hormoneBothIndication hypothyroidism Adverse/ Side effects chest pain, fatigue, nausea Nursing considerations/ Patient Teaching Name Oxybutyin chlorideConcentrationDosage Amount 5 mgRoute POFrequency BIDPharmaceutical class muscarinic antagonistBothIndication neurogenic bladderAdverse/ Side effects dizziness, confusion, UTINursing considerations/ Patient Teaching Make sure patient has the call light and calls before getting out of bedNursing considerations/ Patient TeachingNameConcentrationDosage AmountRouteFrequencyPharmaceutical classHome Hospital or BothIndicationAdverse/ Side effectsNursing considerations/ Patient TeachingNameConcentrationDosage AmountRouteFrequencyPharmaceutical classHome Hospital or BothIndicationAdverse/ Side effectsNursing considerations/ Patient TeachingNameConcentrationDosage AmountRouteFrequencyPharmaceutical classHome Hospital or BothIndicationAdverse/ Side effectsNursing considerations/ Patient Teaching± 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.Diet ordered in hospital? clear liquids Analysis of home diet (Compare to “My Plate” and Diet patient follows at home? regularConsider co-morbidities and cultural considerations):24 HR average home diet:Breakfast: eggs, toast, orange juicePatients at home diet is lacking in many key elements such as protein and fruits. The patient has a deficient in Vitamin D, Vitamin C, Vitamin B, folic acid. The patient is not consuming the recommended amount of daily calcium intake. It is important, especially at her age, to be maintaining a routine amount of calcium intake to help prevent bone problems. Due to the patients recent weight loss surgery and weight loss, it is essential that she obtains plentiful nutrients and vitamins. Lunch:salad, chicken, Dinner: meat (usually chicken) serving of broccoli, serving of corn, one medium potato Snacks: granola barLiquids (include alcohol): waterUse this link for the nutritional analysis by comparing the patients 24 HR average home diet to the recommended portions, and use “My Plate” as a reference.±1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)Who helps you when you are ill?“my family”How do you generally cope with stress? or What do you do when you are upset?“I just try to think of a happy place and time.”Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)“I feel depressed. I have always been depressed.”+2 DOMESTIC VIOLENCE ASSESSMENT Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are safe.”Have you ever felt unsafe in a close relationship? ___No__________________________________________________Have you ever been talked down to?___Yes__________ Have you ever been hit punched or slapped?? _Yes_________Have you been emotionally or physically harmed in other ways by a person in a close relationship with you??________________________No________________ If yes, have you sought help for this?? ______________________Are you currently in a safe relationship? Yes ± 4 DEVELOPMENTAL CONSIDERATIONS:Erikson’s stage of psychosocial development:Generativity vs. Self absorption/Stagnation Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your patient’s age group:“Fulfilling life goals that involve family, career, and society; developing concerns that embrace future generations.”Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:When speaking with the patient, the topic of family was the highlight of the conversation. It was all about how her and her husband were still trying to accomplish life goals in hopes of a better future.Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:Because of all of her co-morbidities, it may become difficult to fulfill her goals and do all the things she hoped to accomplish. +3 CULTURAL ASSESSMENT: “What do you think is the cause of your illness?”"My own mistakes.”What does your illness mean to you?“It is my karma sweetie.”+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)Consider beginning with:? “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.? All of these questions are confidential and protected in your medical record”Have you ever been sexually active?____________________Yes________________________________________________ Do you prefer women, men or both genders? _________________men________________________________________Are you aware of ever having a sexually transmitted infection??______no_________________________________________ Have you or a partner ever had an abnormal pap smear?_______________no______________________________________ Have you or your partner received the Gardasil (HPV) vaccination? ____no_______________________________________ Are you currently sexually active??? ____no_______________________ If yes, are you in a monogamous relationship? ____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?? __________________________________How long have you been with?your current partner?__________10 years___________________________________Have any medical or surgical conditions changed your ability to have sexual activity?? ____No_______________________Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?no±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)What importance does religion or spirituality have in your life? _________________________”God is the reason I am still here.” ___________________________________________________________________________________________________________________________________________________________________________________Do your religious beliefs influence your current condition?_________________________________________________________________________________________________________________”Yes. I have a place to call home when this is all over.” ___________________________________________________________________________________________+3 Smoking, Chemical use, Occupational/Environmental Exposures:1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? No If so, what? How much?(specify daily amount)For how many years? X years(age thru )Pack Years:If applicable, when did the patient quit?Does anyone in the patient’s household smoke tobacco? If so, what, and how much? noHas the patient ever tried to quit?If yes, what did they use to try to quit?2. Does the patient drink alcohol or has he/she ever drank alcohol? No What?How much? For how many years?Volume:(age thru )Frequency: If applicable, when did the patient quit?3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No If so, what?How much?For how many years?(age thru ) Is the patient currently using these drugs? Yes NoIf not, when did he/she quit?4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks“I don't think so.”5. For Veterans: Have you had any kind of service related exposure?N/A± 10 Review of Systems NarrativeGastrointestinalImmunologic X Nausea, vomiting, or diarrhea Chills with severe shakingIntegumentary Constipation Irritable Bowel Night sweats Changes in appearance of skin X GERD Cholecystitis Fever Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS Dandruff Hemorrhoids X Blood in the stool Lupus Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis Hives or rashes Pancreatitis Sarcoidosis Skin infections Colitis Tumor Use of sunscreen Yes SPF: 50 Diverticulitis Life threatening allergic reactionBathing routine: DailyX Appendicitis Enlarged lymph nodesOther: Abdominal AbscessOther: Last colonoscopy?HEENTOther:Hematologic/Oncologic X Difficulty seeing Genitourinary X Anemia Cataracts or Glaucoma nocturia X Bleeds easily Difficulty hearing dysuria Bruises easily Ear infections hematuria Cancer Sinus pain or infections X polyuria Blood TransfusionsNose bleeds kidney stonesBlood type if known: Post-nasal dripNormal frequency of urination: 6-7 x/dayOther: Oral/pharyngeal infection Bladder or kidney infections X Dental problemsMetabolic/Endocrine Routine brushing of teeth DENTURES x/day Diabetes Type: Routine dentist visits 1 x/year X Hypothyroid /HyperthyroidVision screening Every two years Intolerance to hot or coldOther: OsteoporosisOther:Pulmonary X Difficulty BreathingCentral Nervous SystemX Cough - dry Women Only CVA Asthma Infection of the female genitalia X Dizziness Bronchitis Monthly self breast exam Severe Headaches Emphysema Frequency of pap/pelvic exam Migraines Pneumonia Date of last gyn exam? DOESNT REMEMBER Seizures Tuberculosis menstrual cycle regular irregular Ticks or Tremors X Environmental allergies menarche age? 15 Encephalitislast CXR? 1/25/15 menopause age? 45 MeningitisOther: COPDDate of last Mammogram &Result: 2014 NEGATIVEOther:Date of DEXA Bone Density & Result: 2012CardiovascularMen OnlyMental IllnessX Hypertension Infection of male genitalia/prostate? X Depression X Hyperlipidemia Frequency of prostate exam? Schizophrenia Chest pain / Angina Date of last prostate exam?X AnxietyMyocardial Infarction BPH Bipolar CAD/PVDUrinary RetentionOther:X CHFMusculoskeletalMurmur Injuries or FracturesChildhood Diseases Thrombus Weakness MeaslesRheumatic Fever X Pain Mumps Myocarditis Gout Polio X Arrhythmias Osteomyelitis Scarlet Fever Last EKG screening, when? 1/25/15X Arthritis X Chicken PoxOther:Other:Other:General Constitution Recent weight loss or gain Weight lossHow many lbs? 160Time frame? 2 yearsIntentional? yesHow do you view your overall health? The patient appears to look healthy, however, there are many underlying health conditions. Is there any problem that is not mentioned that your patient sought medical attention for with anyone? NoAny other questions or comments that your patient would like you to know?No ±10 PHYSICAL EXAMINATION:General Survey: Medium build, well nourished. Height 5’9Weight70 kgPain: (include rating and location)7 lower backPulseBlood Pressure: (include location)133/73 left upper armRespirations20Temperature: (route taken?)98.1 oralSpO2 94% Room AirOverall Appearance: [Dress/grooming/physical handicaps/eye contact]X clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicapsOverall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]X awake, calm, relaxed, interacts well with others, judgment intactSpeech: [e.g.: clear/mumbles /rapid /slurred/silent/other] X clear, crisp dictionMood and Affect: X pleasant X cooperative X quiet Other:Integumentary X Skin is warm, dry, and intact X Skin turgor elastic X No rashes, lesions, or deformitiesX Nails without clubbing X Capillary refill < 3 seconds X Hair evenly distributed, clean, without verminIf anything is not checked, then use the blank spaces todescribe what was assessed in the physical exam thatwas not WNL (within normal limits) Central access device Type: Mediport Location: R Date inserted: January 12th Fluids infusing? no HEENT: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness X PERRLA pupil size 3/ mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmusX Ears symmetric without lesions or discharge Whisper test heard: (not done)X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesionsDentition: Patient has upper and lower dentures Comments: whisper test was not donePulmonary/Thorax: X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric Percussion resonant throughout all lung fields, dull towards posterior bases (patient was in pain, so this was not done) X Sputum production: thick Amount: small Color: yellow Lung sounds: RUL Clear LUL ClearRML Clear LLL diminished RLL diminished CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - AbsentCardiovascular: X No lifts, heaves, or thrills Heart sounds: X S1 S2 audible Regular X No murmurs, clicks, or adventitious heart sounds X No JVDRhythm (for patients with ECG tracing – tape 6 second strip below and analyze) Calf pain bilaterally negative X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]Apical pulse: Carotid: Brachial: Radial: 2 Femoral: Popliteal: DP: 1 PT:1X No temporal or carotid bruits Edema: No edema [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]Location of edema: pitting non-pitting X Extremities warm with capillary refill less than 3 secondsGI X Bowel sounds active x 4 quadrants; no bruits auscultated X No organomegaly X Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpationLast BM: (date 1 / 23 / 15 ) Liquid Color: Light brown Nausea emesis Describe if present: noneGenitalia: Clean, moist, without discharge, lesions or odor X Not assessed, patient alert, oriented, denies problems Other – Describe:GU Urine output: Clear Color: yellow Previous 24 hour output: 1200 mLs N/A Bathroom Privileges without assistance X CVA punch without rebound tenderness Musculoskeletal: □X Full ROM intact in all extremities without crepitus Strength bilaterally equal at __4_____ RUE ____4___ LUE _____4__ RLE & ____4___ in LLE [rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]X vertebral column without kyphosis or scoliosisX Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesiaNeurological: X Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental examX CN 2-12 grossly intact X Sensation intact to touch, pain, and vibration Romberg’s Negative X Stereognosis, graphesthesia, and proprioception intact X Gait smooth, regular with symmetric length of the strideDTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative DTR were not tested, for there was no reflex hammer available. Romberg was not tested ±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):LabDatesTrendAnalysisEGD was done on 1/24/15 and showed a thickening of the esophagus.Blood Count- the patients blood levels were low due to the anemia WBC- (1/27) 6.6 (1/25) 4.6 low RBC- (1/27) 3.12 low (1/25) 3.66 low Hemoglobin (1/27) 8.6 low (1/25) 10.2 low Hematocrit (1/27) 27.4 low (1/25) 31.3 lowIndices - these were low due to anemia MCHC (1/27) 31 low (1/25) 33 RDW (1/27) 16.4 high (1/25) 15.9 high- due to the number of immature RBC circulating in the system.Thyroid Function test- High due to the comorbidity of hypothyroidism TSH (1/26) 224.80 high Blood gas pH (1/25) 7.580 high PCO2 (1/25) 26.1 low PO2 (1/25) 89.3 O2 sat (1/25)97.7+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:Q4 vitals, EGD on the 28th, Respiratory treatment Q shift, liquids until 9am then NPO (due to EGD) stool sample needed to test for C diff ± 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)1. Ineffective airway clearance related to COPD as evidence by shortness of breath2. Impaired Gas exchange related to COPD as evidence by dyspnea 3. Imbalanced nutrition related to dyspnea as evidence by lack of interest in food4. Risk for infection related to chronic disease process5. Risk for imbalance nutrition related to change in digestive process/ absorption of nutrients ± 15 CARE PLANNursing Diagnosis: Ineffective airway clearance related to COPD as evidence by shortness of breathPatient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Goal on Day Care is ProvidedDemonstrate effective coughing and clear breath soundsAuscultate breath soundsBreath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicated fluid in the airway; wheezing indicated and airway obstructionBreath sounds were auscultated every four hoursMaintain a patent airway at all timesMonitor respiratory patterns: rate, depth, effortA normal repiratort rate for an adult without dyspnea is 12-16. With secretions in the airway the rate will increases. Respiratory patterns were observed every two hours Explain methods useful to enhance secretion removalEncourage the client to use the incentive spirometer. This can help increase sputum clearance and decrease cough spasmsPatient was instructed on the proper way to use the incentive spirometer and the benefitsExplain the significance of changes in sputum to include color character amount and odorObserve sputum noting color, oder, and volumeNormal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous and ofter copiousThe patient was given education on sputum productionIdentify and avoid specific factors that inhibit effective airway clearance Position the client to optimize respirationAn upright position allows for maximal lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs. The patient’s HOB remained higher than 30 degreesInclude a minimum of one Long term goal per care plan±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)Consider the following needs:□SS Consult □Dietary Consult □PT/ OT□Pastoral Care □Durable Medical Needs X F/U appointments X Med Instruction/Prescription □ are any of the patient’s medications available at a discount pharmacy? □Yes □Rehab/ HH □Palliative Care ± 15 CARE PLAN± 15 CARE PLANNursing Diagnosis: Impaired Gas exchange related to COPD as evidence by dyspneaPatient Goals/ OutcomeNursing InterventionsRationale Evaluation Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patients normal range and be free of symptoms of respiratory distressAccess and record respiratory rate, depthUseful in evaluation the degree of respiratory distree or chronicity of the disease processRespiratory rate was evaluated every four hoursElevated head of the bed, assist patient to assume position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep slow breathingOxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing.The head of the bed stayed elevated throughout the day. The patient could not stand laying in the prone position Assess and routinely monitor skin and mucous membrane colorCyanosis may be peripheral or central. Duskiness and central cyanosis indicate advanced hypoxemiaSkin and membranes were assessed every four hoursParticipate in treatment regimen within level of abilityEncourage expectoration of sputumThick, tenacious, copious secretions are a major source of imparted gas exchange in small airways. The patient was instructed on the use of the IS and was offered suction if needed. Evaluate level of activity toleranceDuring severe, acute respiratory distress, patient may be unable to perform basic self-care activities.PT/OT were consulted to work with patient to determine baseline and any self care needs. ReferencesAckley, B. J. (2010). Nursing Diagnosis Handbook: an evidence-based guide to planning care (9th ed). Maryland Heights, MO.: Mosby.Chronic Obstructive Pulmonary Disease?. (n.d.). Retrieved January 30, 2015, from , M. (2014). Relevant Theories and Therapies for Nursing Practice. In Varcarolis' Foundations of Psychiatric Mental Health Nursing: A clinical approach (7th ed., pp. 22-23). Elsevier Saunders.

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