Nursing Care Plan for Six Patients - Case Study Example

TITLE: NURSING CARE PLAN FOR SIX PATIENTS Name: Institution: Date: Abstract Each patient has a right to expect maximum relief from pain. Ambulation factors must therefore be maximized to make sure that the pain is controlled. Research has shown that malfunction in the routine evaluation of pain and pain relief factors could lead to failure of relief mechanisms. Administration of treatment should be done in the above way to ensure that the patient gets the right drug, the right dosage, through the right channel and in the right frequency. Side effects such as drowsiness and sedation should also be monitored and controlled for effective treatment of pain. The management of pain requires that the nurse should focus on finding out the specifics of the disease. This factor is one which makes settling on a specific treatment suggestion for use on a specific client quite hard. A risk assessment based approach makes certain that the nurse or the clinician deals with possible instant and decisive priorities with regard to management in a suitable order while at the same time avoiding any pointless examinations or intercessions. Risk evaluation also lets the nurse make subsequent administrative verdicts with regard to care and check ups, investigations decontamination, the use of improved purging methods, antidotes and outlook to be done in a rational planned way. The risk evaluation process should also seek to deal with the psychological requirements of the patient. Table of Contents TITLE: NURSING CARE PLAN FOR SIX PATIENTS 1 Abstract 2 Table of Contents 3 Nursing Care Plan 4 Introduction 4 Patient 1 4 Mrs. Williams (Bed 15), Age: 41. Time:0730 hours 4 Patient 2 7 Mr. Farrell (Bed 19) Age 51, Time: 0830 hours 7 Patient 3 9 Mrs. Dilma (Bed 20) Age 89, Time: 0900 hours 9 Patient 4 12 Hannah (Bed 16), Age: 24. Time: 1000 hours 12 Patient 5 14 Mr Rassmussen (Bed 17), Age: 88. Time: 1130 hours 14 Patient 6 17 Ben (Bed 18), Age 15. Time: 1200hours 17 Conclusion 21 List of References 21 Nursing Care Plan Introduction Nursing care involves the management of different kinds of pain in patients. Pain could be anything measurable or otherwise and could range from acute to chronic; it could be from a deteriorating condition or be in the form of needing palliative care. Pain can be psychological, emotional or spiritual (Beach et al 2005). The main goal of nursing care is to offer relief with the least of side effects and that is the focus of this paper through nursing care plans of six patients. The paper will focus on the care of the six patients in the following order and at the specific times as indicated. The idea is to help the nurse juggle between the six patients and at the same time offer maximum care Patient 1 Mrs. Williams (Bed 15), Age: 41. Time:0730 hours Subjective: Returned from the OT at 2200 hours the previous evening following a laparoscopic cholecytecomy. Observations at 0600 hours were BP 140/65, pulse 88, respirations 18b/min, Temperature 36.8ºC. 0730 hours Mrs Williams is complaining of abdominal pain. She is ordered Morphine 10 mg IMI and Metoclopramide 10mg IMI. No pain relief has been given since her return to the ward Diagnosis: The diagnosis for this patient could be one of the following complications which normally arise from the OT procedure; gangrene, empyema or perforation. Other related concerns are; “Cholecystitis with cholelithiasis, pancreatitis, peritonitis, psychosocial features of care and surgical intervention” (Mitchell 2007) pain related to surgical injury is usually evidenced by agitation, paleness, high pulse, respiration and systolic blood pressure as evidenced in Mrs. Williams in this case. Other evidence include dilated pupils and an abdominal pain report of 7/10 Objective: The nurse in this case should carry out a comprehensive evaluation of the pain with focus on the position, commencement, and distinguishing features of the pain, length, regularity, eminence, concentration and the impulsive dynamics of the pain. Pain being a subjective experience can only be described by the person who is feeling it so the nurse should get a rating of the pain from the patient in order to be able to plan for treatment effectively. The nurse should then go ahead and reduce or eliminate any factors that could increase the pain in the patient such as panic, exhaustion, dullness and being deficient of facts (Shamiyeh & Wayand 2004). The nurse should also provide Mrs Williams with the best possible pain relief through the use of prescribed analgesics after which she should evaluate the effectiveness of pain management measures already taken by continuously monitoring the patient’s level of pain. The administration of Analgesic should be based on; the order of the administered medication , dose and prescription, the type of analgesic (such as narcotic, non-narcotic or NSAID) depending on the factors mentioned above such as the intensity of pain. If the patient receives narcotic analgesics, then the nurse should introduce the necessary safety measures before the pain becomes too severe and also assess the effects of the analgesic at habitual periods after each administration to see if there are any side effects such as gastric irritation and constipation and document them Rationale of the above actions: Each person experiences pain in an individual manner by means of various socio cultural alteration techniques. Personal factors might also influence pain and tolerance to pain and so any features that could exacerbate pain should be eliminated to improve the whole plan of alleviating it. Another rationale related to the above process is that each patient has a right to expect maximum relief from pain. Ambulation factors must therefore be maximized to make sure that the pain is controlled. Research has also shown that malfunction in the routine evaluation of pain and pain relief factors could lead to failure of relief mechanisms. Administration of Analgesics should be done in the above way to ensure that the patient gets the right drug, the right dosage, through the right channel and in the right frequency. Side effects such as drowsiness and sedation should also be monitored and controlled for effective treatment of the pain. Final Assessment: proper use of analgesics should lead to the desired outcome of relief for the patient within thirty minutes of administration of analgesics. If the desired outcome is not achieved, then other advanced assessment methods should be gathered to help the patient to manage the pain. Patient 2 Mr. Farrell (Bed 19) Age 51, Time: 0830 hours Subjective: Admission at 2300 hours for severe epigastria pain for several hours following his evening meal. Serial ECGs and blood tests attended over night showed no ECG changes and no detectable Troponin leak. He is due to undergo an Endoscopy at 1100 hrs and has been NBM since midnight. IV cannula insitu left hand. 0830 hours Mr Farrell buzzes and says he has central chest pain that he rates at 8/10 on the pain scale. Diagnosis: Acute chest pain r/t myocardial ischemia which often results from “coronary artery occlusion” with loss of/limitation of the flow of blood to an area of the myocardium and necrosis of the myocardium. Within an hour after the intercession of the nurse, Mr. Farrell should experience enhanced relieve in the chest which should be witnessed through a reduction in the rating of the chest pains, the patient’s ability to exhibit reduced anxiety and to sleep comfortably. The patient also needs a decrease in the amount of analgesia or nitro-glycerine. He should also be able to experience an improvement in control which should be confirmed through the expression of a feeling of being in control over the present condition as well as other similar situations occurring in the near future. Objective Nursing Assessment: Some of the first signs that the nurse should look for with regard to Mr. Farrell’s chest pains are; Restlessness, facial grimacing, fatigue, peripheral cyanosis, a weak pulse, cold and clammy skin, palpitations, shortness of breath and elevated temperatures and a consideration of the 8/10 pain scale (Knox County Schools Health Services 1995). The nurse should first of all assess the distinguishing features of the chest pains including where they are situated, their length, their eminence, and concentration, incidence of radiation, impulsive and aggravation features as well as symptoms. The nurse should also tell the client to rate the pains on a scale of 1-10 and write the findings down (Detry 1996). After doing that, the nurse should find out if the patient has ever had any history of cardiac related pains as well as any family history related to the same. The nurse should also assess respirations, BP and heart rate with each episode of chest pain and insist on complete bed rest during the pains in a position that is comfortable and in an environment that is calm. The nurse should also prepare for administration of medicines and keep an eye on the patient to be able to observe any signs of response to therapy and inform a physician about the patient’s condition if the pains do not subside. The nurse should also instruct the patient/family of any side effects of medication, any hostile-signals and symptoms that they should report if observed. Having obtained a 12-lead ECG on admission of the patient, the nurse should use this for evidence of any sort of infarction depending on the outcomes of the ECG as prescribed. The nurse should also take the initiative and administer analgesics such as morphine sulphate , meferidine of dilaudid N as required as well as beta-blockers and calcium blockers as per the physician’s instructions Rationale of the above actions: pain is indicative of myocardial ischemia (MI). Supporting the patient to identify and put a figure on the pain is good for distinguishing between the current situation from any other pre-existing situations or patterns and recognizing any existing complication. This will also play a big role in gathering information that would be very useful in differentiating between the present pain and pain from any subsequent problems and/or complications. It is also important because respirations are likely to increase because of pain and any anxiety that results from it and controlling pain is precedent because it is indicative of ischemia. The above activities will also assist in decreasing myocardial oxygen requirement and workload on the heart and they also help in promoting knowledge pertaining to conformity with therapeutic regimen as well as easing the fear of the unknown. Records of ECG and stat ECG are very important in documentation of any cardiac damage occurrences as well as the location of MI. Morphine is the best drug to manage but analgesics could also be used for purposes of reducing pain and workload on the heart. The administration of calcium channel blockers helps to block sympathetic stimulation. Lower myocardial demand and lessen heart rate. Final Assessment: Within an hour of nursing intervention, the patient should have improved with regard to relieve in the chest and should be able to: declare that the rate of chest pains has decreased, have a good rest and sleep comfortably which is an indication of abridged tension and need lesser amounts of analgesia or nitroglycerin which is basically the goal of the intervention by the nurse. Patient 3 Mrs. Dilma (Bed 20) Age 89, Time: 0900 hours Subjective: Mrs Dilma is a Turkish lady who speaks little English. She is two days post-op # Right NOF. Has previous history of right cerebral vascular accident (CVA) 12 months ago. She is able to follow directions but is at times disorientated to time and place. IV therapy of 1000 ml of normal saline in progress running at 125ml/hour. This infusion was commenced at 0400hours. She is on IV Amoxicillin 1g q6h last given at 0600hours. Her daughter visit as often as possible but lives and works over an hour’s drive from the hospital. 0900 hours observations indicate that Mrs Dilmahas a temperature of 38.3 degrees Celsius, Heart rate of 112 beats/per/min and irregular, BP of 135/80, respirations of 20 per/min, Sp02 of 93% on room air. Diagnosis: Cerebrovascular Accident (CVA). CVA results from the occurrence of ischemia to a section of the brain or brain haemorrhage which results into death of brain cells. It is a leading cause of disability and most patients end up with stroke or being functionally dependent while others are left with permanent disability. Some of the risk factors associated with CVA include: high blood pressure like in the case of Mrs. Dilmahas, heart disease, hypercoagulability, atrial fibrillation, physical lethargy, etc. CVA effects include the interference of blood supply to various parts such as the Circle of Willis, Carotid Arteries and the Vertebral Arteries. Blood supply is also affected like in the case of Mrs. Dilhamas. Ischemic cascades are often characteristics of the disease and they involve a sequence of metabolic episodes namely: “Inadequate ATP adenosine triphosphate production, Loss of ion homeostasis, Release of excitatory amino acids – glutamate, Free radical formation and Cell death” (Albers & Amarenco 2008) Objective Nursing Assessment: confusion in the patient and difficulty in speaking or understanding someone when he or she is speaking, loss of balance and coordination among other factors such as high temperatures, high levels of BP and irregular heart rate are all indications of a transitory Ischemic assault mainly attributed to ischemia of one part of the brain, it lasts not more than 24 hours and sometimes not more than 15 minutes and is a warning sign of the progression of CVA (Chokani-Namame 2005). The nurse should therefore confirm through a CT that the Ischemia attack is not related to brain lesions, the nurse should also take a cardiac evaluation to rule out cardiac mural thrombi, and then administer medication that prevents platelet collection, such as “ASA and Plavix”. She could also administer oral anticoagulants. The nurse should also seek to find out the class of the Ischemic attack because there are two classifications namely; “Ischemic Stroke which is the inadequate supply of blood to brain from partial occlusion of an artery and Hemorrhagic Stroke which is characterized by narrowing of lumen of blood vessels leading to occlusion”. Both are differentiated by how rapid they are at their onset, the size of lesion and the presence of collateral circulation (Kamphuisen & Agnelli 2007). The nurse should evaluate and steady the patient through neurologic screening, application of oxygen if the patient is hypoxic, IV access, checking of glucose and she could also involve an active stroke team (CODE GREEN), and administering of 12-lead EKG. Evaluation of stroke should be determined by establishing the onset, reviewing hx, using of a stroke scale, facial droop, arm drift and abnormal speech. For management purposes, the nurse should do a CT Scan and if there is no haemorrhage he/she should consider fibrinolytic therapy and antiplatelet therapy. If the CT Scan shows there is Haemorrhage, the nurse should consider neuro surgery and if there is no neuro surgery, he/she should; “Monitor BP and treat Hypertension, Monitor Neuro status, Monitor blood glucose and treat as needed, and do Supportive therapy”. Treatment goals include Drug therapy to re-institute blood flow through a blocked artery with drugs such as “tPA (tissue plasminogen activator)”, and the drug should be administered within three hours of onset Rationale of the above actions: The above actions help in maintaining a stable LOC, improve patient’s bodily performance, helps patient in achieving activities and skills that would help them to care for themselves if left alone, they sustain proper functioning of the patient’s body as well as communication capabilities and they also circumvent the problems of stroke as well as help the patient and the family to deal with their situation. Final Assessment: Within 3 hours of evaluation and treatment the patient should come out of the situation Patient 4 Hannah (Bed 16), Age: 24. Time: 1000 hours Subjective: Admitted 1600 hrs yesterday with a threatened miscarriage 12 weeks into her first pregnancy. Passed products of conception on evening shift and is scheduled for a D&C at 1300hours. Has been fasting since midnight. Blood collected at 0600hours for routine pre-operative screening and group and hold. 1000 hours call from the pathology lab – Hannah’ss Hb is 66g/l (reference range is 115-160 g/l). MO reviewed client and ordered a blood transfusion of 2 units of packed. 1100 hours Pathology notifies you that the packed cell blood is ready for collection and infusion into the client. Diagnosis: Incomplete Abortion. An incomplete abortion takes place when some of the products of conception are expelled from the uterus with some being retained leading to bleeding which mainly occurs at the points of uterine blood vessels. The patient in this case basically experiences relentless constrictions and copious bleeding that mostly requires that they be given intravenous (IV) fluids and probably blood products like in the case of Hannah. Generally, a D&C is performed to remove the conception products retained in the uterus during the incomplete abortion. Objective Nursing Assessment: Nursing care for patients experiencing spontaneous abortion differs from one patient to another and mainly depends on the type of abortion that a particular patient is experiencing (Homer et al 2001). However, the basic nursing intervention that is required mainly revolves around making sure that the patient is safe by distinguishing as well as managing bleeding and “hypovolemic shock” whose symptoms range from an “increased heart rate, decreased blood pressure cool and clammy skin, light headedness to confusion”. The nurse in the case of Hannah should also anticipate the need for oxygen therapy as Hannah awaits the Blood replacement. Hannah may also require medications such as “oxytocin (pitocin) or methylergonovine (methergine)” for purposes of causing the uterus to contract and stop the bleeding (Gliebel et al 2005). The nurse should also blood type Hannah and cross-match her in readiness for the blood transfusion. Rationale of the above actions: The nurse should basically examine the imperative signs of the patient, her oxygen infiltration, intake and output as well as results from the laboratory. The nurse in the case of Hannah here will also be required to help Hanna explore her feelings regarding the possible loss. The nurse should also keep in mind any incidence of complication such as infection and disseminated intravascular coagulation (DIC). Infection often occurs due to carrying an expired foetus and could pose a grave danger for Hannah. DIC on the other hand occurs as a result of “over- activation” of the coagulation process in the body meaning that the body produces excess thrombin to control bleeding leading to the conversion of fibrinogen to fibrin and the subsequent clotting of blood in vessels all through the body preventing the flow of blood to critical organs (Medina & Hill 2006). This eventually leads to haemorrhage. In essence, DIC concurrently causes clotting, bleeding and ischemia. The nurse should look out for signs of this which are mainly sudden “succinctness of breath, chest pain and/or cyanosis”. Assessment: Treatment of this is usually aimed at removing the retained products in order to stop the over-activation of the clotting process. And the treatment involves oxygen therapy and blood transfusion which after they have been administered should stop any bleeding and save the life of the patient (Watson et al 1999). The nurse should also acknowledge the loss of the patient in order to enable the patient understand that it is okay to grieve. McKinney et al recommends that such a patient should grieve for about six months to a year (McKinney et al 2005). Patient 5 Mr Rassmussen (Bed 17), Age: 88. Time: 1130 hours Subjective: admission as he is unable to cope at home. He is awaiting nursing home placement and has a past history of hypertension and angina. Has recently found walking difficult and requires assistance to mobilise. 1130 hours the EN advises you that Mr Rassmussen has been found lying on the floor next to his bed. He is crying out and appears to be in pain. He is rubbing his left hip. Diagnosis: The need for palliative care due to intricate psychosomatic and/spiritual requirements i.e. Severe anxiety and intricate social needs, i.e. emergency intervention namely; injury and accompanying physical pain Objective Nursing Assessment: The nurse should start by being organized and giving the family of the patient a short summary of what they should expect, let the patient select a place where they can do that as she awaits his admission and also let the patient decide who should be present during the briefing. Afterwards she can start with current medications. The nurse should remember to be conceding to the fact that some questions may be touching to the emotions and he/she should remember to show deference, gentleness and empathy at all times. The nurse should also consider that there are some hard factors with regard to poor contact, apprehension at the mention of the word “palliative”, trepidation at the progression of disease, patient /relations trying to shield one another, fear of taking strong medications, fear of running out of medications and dying in pain and concerns about the side effects of medication- factors that could become barriers to assessment. Assessment of the patient should take into consideration all characteristic of a basic health assessment, focus on the philosophy of care and the goals of care should also be defined combined with a continuous effort to reach a compromise both with the patient and the family (Onyeka 2010). The use of an Edmonton Symptom Assessment System which usually measures symptoms on a scale of 1 to 10 will be very useful in identifying the experiences of the patient in terms of; “the best and the worst possible pain with regard to the hip injury, the best and the worst possible depression, the best and the worst possible anxiety,” etc. This helps in developing a plan for the care of the patient, helps in the assessment of the nine symptoms that are frequent in palliative care patients, and helps identify the severity of the symptoms at the time of the assessment as well as make available to the nurse a clinical report in the long run. However, it is only a part of a holistic clinical assessment and a tool for use across the board. The use of an Edmonton Symptom Assessment System should be done from time to time on the patient and with more regularity if indicators are not well managed as well as when the nurse wants to assess the effectiveness of medication (Axtell 2008). Rationale of the above actions: The above assessment is very important in identifying and dealing with pain in the patient since it helps identify the rigorousness, position, length or interval, its characteristic as well as any new pain. The assessment also helps identify any exacerbating or lessening factors, the functioning of medications presently being administered on the patient and what all these factors mean to the family (Acton & Kang 2001). With regard to depression, the assessment reveals severity “through questions such as “are you depressed?”), the assessment also helps differentiate between a feeling of sadness and a feeling of depression, it also helps differentiate the current depression from past depression, helps identify any changes in the administration of anti-depressant medications, helps identify any suicidal thoughts and any indicators of hypoactive delirium. With regard to anxiety, the same process is applicable (question such are you anxious should be asked). The evaluation is important t in identifying any specific fears and sources of anxiety help the patient as well as the family to give an identity to the fears and if the patient and family respond with tears the nurse should not try to stop it. This also helps the nurse to get an insight into precedent mechanisms of dealing with anxiety (Beach et al 2005). There is also a need to investigate what support systems the family have in place, and any need for psychosocial support or spiritual care as well as any signs of toxicity from administration of Opioid Final Assessment: Well being: Questions such as “How are you?” are helpful as any positive answers are indicative of a specific condition of relieve and if all scores of an Edmonton Symptom Assessment System are low down and welfare is lofty, then it could be an indication of a potential change. All the above also helps identify good and bad days after which a comprehensive group conclusion should be made on home management, health status and symptoms Patient 6 Ben (Bed 18), Age 15. Time: 1200hours Subjective: Was admitted to the ward overnight following a suspected drug overdose of an unknown drug and alcohol. On admission Ben was uncooperative and begged staff not to tell his parents he was in hospital. Ben is on telemetry monitoring and has been sleeping since admission. He refused to open his eyes when asked and will not answer questions. His 0900 hour observations were all within normal limits. There have been no cardiac arrhythmias records on the telemetry. 1200 hours Ben’s father arrives and demands to speak with the doctor. Ben hears his father’s voice and becomes distressed – he asks that his father not be told anything about why he is in hospital. Diagnosis: Acute Poisoning with Alcohol, substance abuse and withdrawal. Ben’s case is characteristic of Acute Poisoning which occurs to about between 150 and 400 people out of every 100 000 people annually. Acute poisoning is a forceful sickness that is often characterized by aggravated life frightening chronic psychological disorder. It include cases of: deliberate poisoning, recreational drug abuse like in the case of Ben, and occupational poisoning and has different kinds of appearances and management.. Objective Nursing Assessment: The nurse in this case needs to use a very uncomplicated but tough medical approach aimed at dealing with the homogeneity but which will allow for a well tailored management of the specific problem that the patient has and at the same time one that is available at that particular moment in the facility. The nurse is required to first and foremost carry out a risk assessment to ascertain what course of action he/she should take with consideration of any potential complications that might occur with regard to the patient. The risk assessment needs to be quantitative and should consider factors such as the agent to be used, dosage, and the amount of time needed for intake, clinical features and any further developments as well as the patient’s factors (“age, weight and co-morbidities”). The management of toxins related cases requires that the nurse should focus on finding out the specific drug taken by the patient. This factor is one which makes settling on a specific treatment suggestion for use on a specific client quite hard. A risk assessment based approach makes certain that the nurse or the clinician deals with possible instant and decisive priorities with regard to management in a suitable order while at the same time avoiding any pointless examinations or intercessions (Murray et al 2011). Risk evaluation also lets the nurse to make subsequent administrative verdicts with regard to care and check ups, investigations decontamination, the use of improved purging methods, antidotes and outlook to be done in a rational planned way. The risk evaluation process should also seek to deal with the psychological requirements of the patient. Table 1: Risk Assessment-based approach to toxic substance management for Ben Risk Assessment: Agent, dosage. Time since ingestion, Clinical features and course, patient factors Supportive care and monitoring Investigations: Screening – 12-lead ECG, paracetamol, specific Decontamination Enhanced elimination Antidotes Disposition The only factor that is greater than risk assessment is resuscitation so risk assessment should be done as soon as the patient is admitted. Ben is in a normal mental state in which case he should be wiling to give a good history from which the nurse can build a risk assessment (Ashbourne et al 1989). However, Ben is not willing to talk and this stands in the way of acquiring a history directly from him therefore other backup strategies could be used to acquire such as: asking ambulance officers to search for any substances he might have used, inspecting his previous medical records, asking his father who is present at the hospital about any potential substance that he might know which his son might have used (Albertson et al 2001). Alternatively, since Ben does not want his father to be told why he has been admitted, the nurse could ask him for information in exchange for keeping it a secret just for the purposes of obtaining a direct history from him because all the above alternatives tend to give an inaccurate assessment and are only used in a “worst case scenario”. Rationale of the above actions: Risk Assessment is very critical as it allows the nurse to identify any possible dilemma and make precise objective judgments concerning whichever steps he / she should take regarding: “supportive care and monitoring, screening and specialized testing, decontamination, enhanced elimination, antidotes and disposition” a risk assessment helps identify the clinical status of the patient because the substance taken by the patient, dosage and timing since the ingestion of the substance must correlate with the existing status of the patient and if they don’t, then the assessment must be reconsidered and adjusted. In most cases risk assessment allows for an early detection of any trivial medical poisonings (daly & Little 2006). It also restores confidence in the nurse, family members and patient and saves them any avoidable intercessions, investigations and observations and also saves time and the length of hospital stay. Final Assessment: The above actions should enable the nurse administer the right treatment which should make the patient better. Conclusion Nurses must act in an accountable manner at all times to be able to manage the care of patients properly and alleviate pain. They should also hone their skills always and stay up to date in knowledge and skill. List of References Acton, G, & Kang, J, 2001, Interventions to reduce the burden of caregiving for an adult with dementia: A meta-analysis, Res Nurs Health vol.24 , 349-360. Albers, G, & Amarenco, P, 2008, Antithrombotic and Thrombolytic therapy for ischemic Stroke: American college of chest Physicians Evidence-Based Clinical Practice Guidelines New York: Chest. Albertson, T, Dawson, A, & de Latorre, F, 2001, Toxicologic-oriented advanced cardiac life support, Annals of Emergency Medicine Vol 37 , 78-90. Ashbourne, J, Olson, K, & Khayam-Bashi, H, 1989, Value of rapid screening for acetaminophen in all patients with intentional drug overdose, Annals of Emergency Medicine Vol 18 (10) , 1035-1038. Axtell, A, 2008, Depression in palliative care, J Palliat Med. Vol 11 , 529-530. Beach, S, Schulz, R, & Williamson, G, 2005, Risk factors for potentially harmful informal caregiver behavior, J Am Geriatr Soc Vol 53 , 255-261. Chokani-Namame, 2005, Acute Coronary Syndromes Patient's Characteristics: Optimizing Outcomes in the Pre-Hospital Phase of Care, Pretoria: University of South Africa. Daly, F, & Little, M, 2006, A risk assessment based approach to the management of acute poisoning, Emergency Medicine Journal Vol. 23 , 396-399. Detry, R, 1996, The pathophysiology of myocardial ischaemia, European Heart Journal Vol 17 , 48-52. Gliebel, C, Halvorsen, J, Goleman, T, & Day, A, 2005, Management of spontaneous abortion, American Family Physician 72 (7) , 1243-1250. Homer, C, Matha, D, & Jordan, L, 2001, Community-based continuity of midwifery care versus standard hospital care: a cost analysis, Australian Health Review , 3-6. Kamphuisen, P, & Agnelli, G, 2007, What is optimal Pharmacological prophylaxis for the prevention of deep-vein thrombosis and pulmonary embolism in patients with acute ischemic stroke? Thromb Res Vol 119 , 265. Knox County Schools Health Services, 1995, ABDOMINAL/EPIGASTRIC PAIN: GASTROENTERITIS DIAGNOSTIC GUIDELINES, Paediatric Nursing Vol 21 (3) , 217. McKinney, E, James, S, Murray, S, & Ashwill, J, 2005, Maternal Child nursing. St. Louis: Elsevier. Medina, T, & Hill, D, 2006, Preterm premature rupture of membranes: Diagnosis and management, American Family Physician 73 (4) , 659-665. Mitchell, M, 2007, Nursing Intervention for day case laparoscopic cholecystectomy, Nursing Standard Vol 22 (6) , 35-41. Murray, L, Daly, F, Little, M, & Cadogan, M, 2011, Toxicology Handbook. Sydney, Edinburgh, London, New York, Philadelphia, St, Louis, Toronto: Churchill Livingstone Elsevier. Onyeka, T, 2010, Psychosocial Issues in Palliative Care: A Review of Five Cases, Indian Journal of Palliative Care Vol 16 (3) , 123-128. Shamiyeh, A, & Wayand, W, 2004, Laparoscopic cholecystectomy: early and late complications Current Concepts in Clinical Surgery Vol 389 , 164-171. Watson, L, Potter, A, & Donohue, L, 1999, Midwives in Victoria, Australia: a survey of current issues and job satisfaction Midwifery Vol 15 , 12-28. Read More