R.W. is an 84 year old Caucasian male who was admitted to 2 southeast at Clark Memorial Hospital in Jeffersonville, in with a diagnosis of anemia secondary to gastrointestinal bleeding. According to R.W. “everything was fine until I moved here. My doctor in Virginia had me fixed. I just can’t wait until they cut me open and fix this hole.”
R.W> is allergic to penicillin. He denies the use of tobacco or alcohol. His past medical history includes coronary artery disease status post angioplasty in 1993; atrial fibrillation; amniodarone induced thyroid toxicity; and electrocardiogram in October 2006 that revealed an ejection fraction of 55%, pulmonary hypertension, and marginal mitral regurgitation; hypertension; deep vein thrombosis in his left lower extremity in 2007; anemia secondary to possible gastrointestinal bleeding; a colonoscopy in 2003 and 2007 for possible diverticulosis; cholecystectomy; congestive heart failure; depression; and appendectomy. R.W. is also on the following medications: sertraline hydrochloride, ferrous sulfate, metronidazole, levofloxacin, vitamin K, lanoxin, metoprolol succinate, diltiazem, omeparazole, and potassium chloride.
R.W. lives with his wife in a patio home in Jeffersonville, IN. He has been married for 60 years and has three children. He served in WWII and is currently retired.
Gordon’s Functional Health Assessment
1) Health Perception – Health Maintenance R.W. states his general health has been “excellent until I moved over here eleven years ago. I have had gallstones, gallbladder, kidney, and appendix gone.” He denies having any colds in the past year. “I eat right, don’t use alcohol or tobacco” was how he responded when asked what the most important things he does to keep healthy. He did fall twice in the morning the day I took care of him but he fell on his buttocks and didn’t sustain any injuries according to the nurse I took report from. He states it has “basically been easy to follow suggestions from nurses in the past I guess.” When he first noticed symptoms he “went to the doctor and ended up in the hospital.” The results of going to the doctor and being admitted were a diagnosis of possible high grade obstruction with gastrointestinal bleeding. When asked what things are important to you in your healthcare, R.W. replied “care is great.”
2) Nutritional – Metabolic Pattern When asked to describe his typical daily food intake, R.W. said “breakfast is usually a blueberry muffin with a small glass of grape juice; lunch is a toasted cheese sandwich; and dinner is steak or spaghetti, just the normal stuff.” R.W. denies snacking between meals or the use of any dietary supplements. He states his typical fluid intake consists of “one and one half (20 oz) bottles of water and an occasional glass of black tea.” He also stated he has recently lost 15 pounds but has not noticed any loss or gain in height. He described his appetite as “rotten.” He denies any discomfort with eating or drinking as well as any dietary restrictions. However he did state he has difficulty swallowing “those damn big pills.” He reported that he “heals very good.” The only sink problems he identified are “it’s all wrinkled, it’s very dry, and I have loads of age spots.” He denies any dental problems but said “I only have nine on top and ten on bottom.”
3) Sleep – Rest Pattern R.W. states he is “normally” generally rested and ready for daily activities after sleep. He denies having any problems falling asleep and “I go to bed at eight and sleep until seven.” He denies using sleep aids or experiencing nightmares. The only time he experiences early waking is “just to go to the bathroom.” His rest-relaxation periods were described as the following “I am relaxed all the time. I can’t find anything to do. I used to make furniture and all that stuff.
4) Elimination Pattern R.W. states his typical bowel elimination pattern is “regular with three formed stools per day.” His typical urinary elimination pattern is “four times per day for the last few months.” He denies any problems with controlling his bowel or bladder as well as any excessive perspiration or odor problems.
5) Activity – Exercise Pattern When asked about sufficient energy for desired or required activities, R.W. stated “no I do not. I don’t’ have any energy anymore.” He denies any type of exercise and states “I can’t because of my legs.” In his spare time R.W. enjoys “going out to eat one to two times per week, collecting coins, matlock steins, tobacco jars, and humidors.” Most of the perceived abilities were coded as 0 which means that full self care is applicable. General mobility was coded as 1 which means it requires use of equipment or device. R.W. stated “I use a walker or cane to get around.”
6) Cognitive – Perceptual Pattern R.W. denies any difficulty hearing or using hearing aids. When asked he said “no, I hear terrific.” He states he does have problems with his right eye and wears glasses. R.W. said “Yeah, I can remember better than I used to” when asked if he noticed any changes in memory lately. When asked about important decision being easy or difficult to make, R.W. stated “they are easy as long as I have money to pay for it.” R.W. stated the easiest way for him to learn things is “by reading and doing it” and he denies any difficulty learning. He stated “no, I was an engineer for the state of New York for 27 years.” He also denies any pain or discomfort.
7) Self – Perception – Self – Concept Pattern When asked how R.W. would describe himself he said “rotten” with a big smile on his face. When asked if he feels good or not so good about himself most of the time, he stated “I feel good. I have accomplished a lot. I have built three houses.” R.W. stated “Oh yeah, I can’t walk anymore or do wood work anymore, and I used to paint but not in a very long time” in response to being asked if he has experienced any changes in his body or things he could no longer do. When asked the follow up question of if it has been a problem he stated “No, not really. I can still go out in the garage when it gets decent weather again. R.W. denied any changes in the way he felt about himself or his body since the illness started, but he did say “I knew something had to be done.” R.W. stated the following things made him angry: “his neighbor’s barking dog and his wife asking over and over ‘what did you say’; the following annoys him: “road hogs with 150 pickups”; the following makes him fearful: “nothing”; and the following makes him anxious: “the thought of people breaking in my house and stealing my nice gold pieces or my matlock steins.” R.W. also stated he “feels like I have lost hope right now. I feel that way very much so.”
8) Role – Relationship Pattern R.W. is married and lives with his wife in a patio home in Jeffersonville, IN. He has three children but denies any difficulty handling any family problems. He denies that his family depends on him for things, and states “I don’t have any left.” He states he manages this because “my kids are on their own.” When asked how his family or others feel about his illness or hospitalization he reported “my oldest son is very sad that I’m in here.” He denies having any close friends and says “they are all gone.” He states he does feel lonely occasionally. When asked if he has sufficient income for his needs, R.W. stated “Yes. I have a good pension and we have a little money left.” When asked if he felt like he was a part of or isolated in the neighborhood where he lives he stated “we don’t associate with anyone in the neighborhood.”
9) Sexuality – Reproductive Patterns R.W. stated “I have not been sexually active in 15 years.”
10) Coping – Stress Tolerance Pattern When asked if he has experienced any big changes in his life in the last year or two, R.W. said “I’m sick now, I wasn’t before.” He denies feeling as if he’s in a crisis. He stated his wife is who he feels is most helpful when talking things over and that she is available whenever he needs her. He also stated he is “relaxed most of the time” and “it’s the way I have always been.” He denies the use of any medicine, drugs, or alcohol to help him relax. R.W. also denies having any big problems in his life.
11) Value – Beliefs Pattern R.W. stated he generally gets the things he wants from life. He denied having any important plans for the future and stated “I’m 84 years old, no we have done everything.” When asked if religion is an important part of his life, R.W. said “not anymore.”
On the afternoon of February 27, 2008, R.W.’s vital signs consisted of a blood pressure of 144/81, a pulse of 81, a respiratory rate of 16, an oral temperature of 96.6o F, an oxygen saturation of 93%, and a pain level of 0 on a 0-10 scale. He weighs 83kg (183 lbs) and is 190.5cm (75”) tall. Upon entering his room he was laying in bed in a semi-fowler’s position. Daily ADL’s were performed in the morning. Safety measures observed for this patient were two bed rails raised, call light within reach, and the over bed table within reach.
R.W. appeared his stated age of 84. He is alert and oriented to person, place, and time. His skin is warm, pink, and evenly pigmented. He appeared to be adequately nourished. He was lying in bed. There were no physical deformities noted. R.W. is ambulatory and up ad lib with assistance. His facial expression and affect appeared to be appropriate. His speech is smooth and articulate without any difficulties. He is well groomed with appropriate hygiene. (Jarvis, 2004, p. 836)
The patient’s skin is warm, pink, and evenly pigmented with the exception of multiple senile lentigines. No ecchymosis was noted. Skin turgor was present. The patient’s nails were smooth bilaterally on his hands and feet. (Jarvis, 2004, p. 837)
Head, Neck, Regional Lymphatics, Nose, Mouth & Throat
The patient’s skull is symmetrical and centered midline. His temporal artery is 2+ and there were no pops or locking in the patient’s temperomandibular joint. His facial expression was appropriate and his facial features were symmetrical. No edema, lesions, or involuntary movements were noted. His accessory neck muscles appeared to be symmetrical. He was able to complete all range of motion without any evidence of pain. His pupils were approximately 3mm bilaterally and reacted equally to light accommodation. (Jarvis, 2004, p. 837)
No enlarged lymph nodes were noted upon palpation. Parotid gland was firm and non tender. His trachea is centered midline. Palpation also reveled non-enlarged thyroid. Auscultation of the thyroid revealed no evidence of bruit. (Jarvis, 2004, p. 837)
The patient’s nose is symmetrical with no visible deformities. Both nares were patent. No lesions were noted. No otoscope was available to inspect the nasal mucosa. Palpation of the external nose yielded soft and non-tender tissue. The patient denied any pressure when the frontal and maxillary sinuses were palpated. (Jarvis, 2004, p. 837)
The patient’s lips are symmetrical, pink, and dry without any lesions. The teeth he has remaining appeared to be in proper alignment. No dental caries were noted. His oral mucosa including his tongue, gums, and buccal mucosa were moist, pink, and free of any visible lesions. He still had his tonsils and visual inspection revealed the tonsils to be graded as 2+. (Jarvis, 2004, p. 837)
Thorax & Lung Assessment
The patient was lying on his bed. His respirations were regular, deep, and non-labored. The patient’s lateral anterior to posterior diameter is within normal limits of 1:2, with a normal elliptical shape with downward slope. Chest expansion was symmetrical anteriorally and posteriorally. Tactile fremitus revealed vibrations over all nine areas. No masses or tenderness were noted. Percussion yielded resonance as the predominant note over the lung fields. Diaphragmatic excursion yielded a span of 3.5cm which is within normal limits. Percussion was also performed over the anterior chest and resonance was the predominant tone heard as well. Auscultation revealed clear lung fields without the presence of any adventitious breath sounds. (Jarvis, 2004, p. 836, 838-839)
Heart & Peripheral Vascular Circulation and Lymphatics Assessment
Palpation of the carotid pulses were 2+ bilaterally and auscultation revealed no presence of bruit. No lifts or heaves were noted upon visual inspection. Auscultation of the heart revealed a regular rate and rhythm without the presence of any extra heart sounds. Apical pulse was 79 upon auscultation. Upper extremity capillary refill was less than two seconds bilaterally. The epitrochlear node was not palpable bilaterally. Allen’s test was performed and both the brachial and radial arteries are patent bilaterally. Palpation of the left lower extremity revealed diminished (1+) posterior tibial as well as dorsalis pedis pulses. Edema was graded as 1+. Homan’s sign was not performed due to the presence of deep vein thrombosis. Palpations of the right lower extremity revealed 2+ posterior tibial as well as dorsalis pedis pulses. Homan’s sign was negative and edema was present. (Jarvis, 2004, p. 839-840, 893)
Visual inspection of the abdomen revealed a flat symmetrical abdomen with an inverted umbilicus. No pulsations or movements were noted. Auscultation of the abdomen revealed positive bowel sounds in all four quadrants. Palpation was performed with the patient lying on his back with his knees bent. No masses or tenderness were noted during light or deep palpation. Percussion yielded tympany over the entire abdominal cavity. The liver was palpated using the hooking technique and yielded a non-tender, non-enlarged liver. Patient denied any pain when rebound tenderness, inspiratory arrest, ileoposas muscle test, and the obturators tests were performed. (Jarvis, 2004, p. 839-840)
The patient’s spine is positioned midline. His cervical, thoracic, and lumbar curves are within normal limits. His scapulas are equally aligned and symmetrical, as well as his iliac crests. The patient is able to move his haw without any difficulties as well as tile his head forward, backward, and side to side. He is able to hypoflex, internally rotate, and abduct his shoulders. He is also able to flex, extend, supinate, and pronate his wrists. No radial or ulnar deviations were noted and the patient was able to bend and spread his fingers as well as touch each finger to his thumb. Phalen’s and Tinel’s tests were performed and the patient denied any pain or discomfort with both. The patient was able to raise his legs with his knees extended, bend his knees toward his chest, abduct and adduct his legs with help. He was able to freely flex, extend, and internally and externally rotate his feet as well as wiggle, bend, and spread his toes apart. Buldge sign, Ballottment’s teat, and McMurray’s tests were all negative. (Jarvis, 2004, p.841-842)
Nervous System Assessment
The patient’s appearance was appropriate to the situation. He was clean shaven, well groomed, and had good hygiene. He responded appropriately to environmental stimulus. His speech is appropriate to his education level, he is articulate and his speech is steadily paced. The patient was alert and oriented to person, place, and time and he is able to complete is thoughts without wandering. His recent memory was tested using a 24 hour diet recall and his remote memory was tested by asking what his first job was. The patient was able to recall three of the four words in the unrelated words test after ten minutes. The following cranial nerve tests were performed:
CN I/Olfactory -- the patient was able to recognize the smell of an alcohol pat when each nares was occluded with his eyes closed
CN II/Optic -- the patient was able to read news print at an arm’s length
CN III, IV, VI/ Occulomotor, Trochlear, Abducens -- pupils constricted in response to light, no evidence of nystigmus noted, and the patient was able to follow the cardinal direction by only moving his eyes
CN V/Trigiminal -- patient was able to determine when the tip of a gauze was touched to his forehead, zygomatic arch, and his chin. The patient was able to masticate and muscle strength was graded as 5+. I was not able to separate his haws by pushing down on his chin with his teeth clinched
CN VII/Facial -- mobility and symmetry were tested by asking the patient to smile, frown, close his eyes tight against efforts to open them, lift his eyebrows, show his teeth, puff his cheeks, and then pressing his puffed cheeks in.
CN VIII/Acoustic -- Romberg was not tested due to unsteady gait. Patient was able to hear me whispering his name from several feet away. No tuning fork was available to perform Weber’s or Rinne’s test.
CN IX/Glossopharyngeal -- uvula and soft palate rose when the patient said “Ahh” and the tonsilar crypts moved midline.
CN X/Vagus -- I did not test the gag reflex
CN XI/Spinal Accessory -- the patient attempted to rotate his head side to aide against resistance as well as shrug his shoulders against resistance but was unsuccessful
CN XII/Hypoglossal -- when the patient stuck out his tongue no deviations from the midline were noted. He was able to clearly articulate the words light, tight, and dynamite.
The patient’s gait was very unsteady so I did not have him perform tandem waling, shallow knee bends, or hop on one foot. Romberg was not tested for the same reason. The patient was able to rapidly touch each finger to his thumb. He was able to sense light touch, pain, and temperature changes in both his arms and his right leg. When his eyes were closed he was also able to determined which direction in space I was pointing his toe. Also with his eyes closed he was able to identify a knee and he correctly identified the number two when it was drawn on his palm with my finger. His deep tendon reflexes were not tested do to the absence of a percussion hammer. Clonus could not be elicited. When the plantar reflex was tested on the right foot, plantar flexion of his toes occurred. (Jarvis, 2004, p.842)
With anemia caused by bleeding, iron and other components of the erythrocyte are lost from the body. Blood loss may be acute or chronic. Acute blood loss carries a risk for hypovolemia and shock. The cells are normal in size and color. A fall in the red blood cell count, hematocrit, and hemoglobin are caused by hemodilution resulting from movement of fluid into the vascular compartment. The hypoxia that results from blood loss stimulates red cell production by the bone marrow. (Porth, 2005, p. 304) Anemia is a condition in where the hemoglobin concentration is lower than normal and it reflects the presence of fewer then normal erythrocytes within the circulation. As a result, the amount of oxygen delivered to body tissues is also diminished. (Smeltzer, Bare, Hinkle, & Cheever, 2008, p.1045)
Current Lab Values
The patient is currently taking ferrous sulfate to treat his anemia. He is also receiving transfusions of fresh frozen plasma and packed red blood cells to help counteract the fluid loss due to his gastrointestinal bleeding. He is currently taking and receiving the following medication to relieve the signs and symptoms of his current or secondary problems:
Diltiazem hydrochloride 120mg
- Classified as an antianginal, diltiazem hydrochloride inhibits calcium ion influx across cardiac smooth muscle cells, decreasing myocardial contractility and oxygen demand. It also dilates coronary artery and arterioles. RW is on this medication for hypertension. (Kluwer, 2007, p. 271-272)
Ferrous sulfate 325mg
- Classified as a hematinic, ferrous sulfate provides elemental iron as an essential component in the formation of hemoglobin. RW is on this medication for iron deficiency. (Kluwer, 2007, p. 889-890
- Classified as an inotropic, digoxin inhibits sodium-potassium activated adenosine triphosphate, promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contractility. It also acts on the central nervous system to enhance vagal tone, slowing conduction through the sinoatrail and atrioventricular nodes. RW is on this medication for atrial fibrillation. (Kluwer, 2007, p. 238-239)
- Classified as a fluoroquinolone, levofloxacin inhibits bacterial DNA gyrus and prevents DNA replication, transcription, repair, and recombination in susceptible bacteria. RW is on this medication for acute pelvic inflammatory disease. (Kluwer, 2007, p. 143-144)
Metoprolol succinate 50mg
- Classified as an antihypertensive, metoprolol succinate’s actions are unknown. It is believed to be a selective beta blocker that selectively blocks B1 receptors, decreasing cardiac output, peripheral resistance, and cardiac oxygen consumption, and depresses rennin secretion. RW is on this medication for hypertension. (Kluwer, 2007, p. 313-314)
- Classified as an amebicide/antiprotozoal, metronidazole is a direct acting trichomonacide and amebicide that works inside and outside the intestines. It’s thought to enter the cell of microorganisms that contain nitroreductase, forming unstable compounds that bind DNA and inhibit synthesis, causing cell death. RW is on this medication to prophylactically prevent post operative infection in contaminated or potentially contaminated colorectal surgery. (Kluwer, 2007, p. 20-22)
- Classified as an antiulcer drug, omeprazole inhibits the activity of the acid pump and binds to hydrogen potassium adenosine triphosphate at the secretory surface of gastric parietal cells to block the formation of gastric acid. RW is on this medication for frequent heartburn. (Kluwer, 2007, p. 718-719)
Potassium chloride 20mEq
- Classified as an electrolyte/replacement solution, potassium chloride replaced potassium and maintains potassium levels. RW is on this medication for hypokalemia. (Kluwer, 2007, p. 879)
Sertraline hydrochloride 50mg
- Classified as an antidepressant, sertraline hydrochloride’s action is unknown. It is thought to be linked to the drug’s inhibition of central nervous system neuronal uptake of serotonin. RW is taking this medication for depression. (Kluwer, 2007, p. 481)
Vitamin K 5mg
- Classified as a vitamin and mineral, vitamin K has an antihemorrhagic factor that promotes hepatic formation of active coagulation factors. RW is on this medication for hypoprothrombinemia. (Kluwer, 2007, p. 1221-1222)
- Alert and oriented x3
- Patient is able to perform all activities of daily living with minimal assistance
- The patient knows to ask for assistance with ambulation
- The patient understand what is going on medically
- The patient is pleasant to enter act with
- The patient understands use of the call light
- The patient’s family shows concern for his well being
- Coronary artery disease
- Atrial fibrillation
- Aminodarone induced thyroid toxicity
- Marginal mitral regurgitation
- Deep vein thrombosis
- Severe anemia
- Congestive heart failure
- Coping mechanisms
- Falls risk
- Being grumpy in the morning
- Incontinence due to bowel prep
- acute pain r/t irritated mucosa from acid secretion
- deficient fluid volume r/t gastrointestinal bleeding
- fatigue r/t loss of circulating blood volume, decreased ability to transport oxygen
- fear r/t threat to well being
- imbalanced nutrition: less than body requirements r/t nausea and vomiting
- risk for ineffective coping r/t personal vulnerability in crisis, bleeding, or hospitalization
- anxiety r/t cause of disease
- delayed surgical recovery r/t decreased oxygen supply to body, increased cardiac workload
- impaired memory r/t anemia
- ineffective health maintenance r/t deficient knowledge regarding nutritional and medical treatment of anemia
- ineffective protection r/t bleeding disorder
- risk for injury r/t alteration in peripheral sensory perception
Nursing Care Plan
After collecting and analyzing the data that is pertinent to RWs health and lifestyle history the preceding nursing diagnosis were prioritized and the top three were chosen and a care plan was constructed. The primary nursing diagnosis chosen to elaborate on include: deficient fluid volume r/t gastrointestinal bleeding, fatigue r/t loss of circulating blood volume, and acute pain r/t irritated mucosa from acid secretion. The following care plans included nursing diagnosis, nursing interventions, rationale to support each intervention, patient goals, and evaluation of each goal.
1) Deficient fluid volume r/t gastrointestinal bleeding AEB GI Bleeding
2) Fatigue r/t loss of circulating blood volume AEB decrease in H&H values
3) Acute pain r/t irritated mucosa from acid secretion AEB patient stating pain 6
“I’m loosing blood but I think its coming from my lungs”
HGB 8.7, HCT 25.9, RBC count 2.99
1a) Client will maintain normal blood pressure, pulse & body temperature for the entire shift
1b) Client will maintain elastic skin turgor for the entire shift
1c) Client will maintain orientation to person, place, and time for the entire shift
2a) Client will verbalize increased energy and improved well-being by end of stay.
2b) Client will explain energy conservation plan to offset fatigue by the end of stay
2c) Client will explain energy restoration plan to offset fatigue.
3a) Client will use a pain rating scale to identify current pain intensity & determine comfort goal by end of shift.
3b) Client will report that pain management regimen relieves pain to satisfactory level with acceptable & manageable side effects by end of shift.
3c) Client will describe how unrelieved pain will be managed by end of shift.
1a) Monitor vital signs of client with deficient fluid volume every 4 hours
1b) Monitor for inelastic skin turgor.
1c) Monitor for decreased level of consciousness.
2a) Determine with help from the primary care provider whether there is a physiological or psychological cause of fatigue that could be treated.
2b) Help the client identify essential and nonessential tasks and determine which can be delegated.
2c) Encourage the client to keep a journal of activities, symptoms of fatigue, including the client’s perception of potential caused of fatigue and possible interventions to alleviate fatigue.
3a) Assess pain in a client using a self-reported 0-10 numerical pain rating scale or the faces pain scale.
3b) Question the client regarding pain at frequent intervals, often at the same time as doing vital signs.
3c) Question the client regarding the level of pain that they think is appropriate to achieve a state of comfort and appropriate function
1a) A decreased pulse pressure is an earlier indicator of shock than is the systolic blood pressure
1b) This is a symptom of decreased body fluids
1c) This is a symptom of decreased body fluids
2a) If an etiology for fatigue can be determined; fatigue should be treated according to the underlying cause.
2b) The nurse can help the client look at life realistically to balance available energy and energy demands.
2c) Chronic fatigue is a disabling illness characterized by persistent fatigue accompanied by rheumatilogical, cognitive, and infectious appearing symptoms
3a) Single-item ratings of pain intensity are valid and reliable as measures of pain intensity.
3b) Pain assessment is as important as taking vital signs and the American Pain Society suggests applying the concept of pain assessment as the 5th vital sign
3c) The pain rating that allows the client to have comfort and appropriate function should be determine as this allows a tangible way to measure outcomes of pain mgt.
Evaluation of OUTCOMES
1a) Normal vital signs were maintained for the entire shift.
1b) Elastic skin turgor was maintained for the entire shift.
1c) A & O x3 was maintained for the entire shift.
2a) Client verbalized increased energy/well being by end of shift.
2b) Client explained energy conservation plan.
2c) Client explained energy restoration plan.
3a) Client used a pain rating scale to identify current pain intensity.
3b) Client reported pain at acceptable level and manageable side effects.
3c) Client described how unrelieved pain will be managed.
Ackley, B., & Ladwig, G. (2006). Nursing Diagnosis Handbook A Guide to Planning Care (7th ed.). St. Louis. MO: Mosby.
Jarvis, C. (2004). Physical Examination & Health Assessment (4th ed.). St. Louis, MO: Saunders
Kluwer, W. (2007). Nursing 2007 Drug Handbook (27th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Porth, C. (2005). Pathophysiology Concepts of Altered Health States (7th ed.). Phildelphia, PA: Lippincott Williams & Wilkins. 6 6
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. 6
Author: Jason Hawkins RN, BSN, MSN
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