NUR250 Medical Surgical Nursing 1
Question:
Topic: Nursing care of a patient with a respiratory problem
Case: Meet Neville
Shift handover:
Neville is a 62 year old man with moderate, established chronic obstructive pulmonary disease (COPD) and a long history of smoking.
He was admitted 2 days ago with worsening dyspnoea, cough and increasingly purulent sputum production. He reports he developed a cold a few days before admission but his usual preventative medications didn’t relieve symptoms and he is now unable to take more than a few steps before having to rest.
Since admission, his upper respiratory symptoms have improved but he reports his dyspnoea and shortness of breath on exertion have not yet returned to what is normal for him. He remains tachycardic and his blood pressure is slightly elevated. Nasal prong oxygen remains in place.
Medical orders are for nasal prong oxygen @ 2L/min to maintain oxygen saturations 88-92%; spirometry before and after nebulisers; high protein, high carbohydrate diet; push oral fluids, fluid balance chart, food chart and second daily weighs.
Current medications are ipratropium bromide and salbutamol nebulisers, oral prednisone, oral amoxicillin, prn paracetamol and coloxyl. Pneumococcal and flu vaccines have been ordered to be administered before discharge once his condition has improved.
Neville has tried to stop smoking on a number of occasions. He has cut down to 10 cigarettes per day but is having difficulty stopping completely. He lives with his wife who continues to be very supportive.
Tasks:
Based on the handover you received at the beginning of your shift today, other information included below and current reliable evidence for practice, address the following 5 tasks.
Do not make up or assume information in relation to or about Neville, the photo is not an indication of his age or appearance. Only use what you know from the information you received today.
Task 1: Understanding nursing problems
After handover you consider and plan the nursing care that Neville requires today.
You recognise that there are 5 key nursing problems for Neville today:
- Ineffective airway clearance
- Impaired gas exchange
- Risk of impaired ventilation
- Imbalanced nutrition: less than body requirements
- Risk for infection
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice
- Explain the specific underlying cause/s (aetiology) or reason/s for each of the nursing problems above.
Task 2: Care planning
In addition to the nursing problems above, you also recognise that Neville requires fundamental nursing care today and your role and responsibility as the nurse caring for Neville today is to keep him:
- Safe
- Clean and dressed
- Warm and comfortable
- Fed
- Hydrated
- Rested
- Mobile
- Toileted
Based solely on the handover you have received select five (5) fundamentals of care from the list above and develop a plan of care for each one identifying:
- The related nursing problem
- The underlying cause or reason (ie, what the 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, the nursing responsibilities associate with administering each medication 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 explainwhy Neville has been prescribed: o Oral prednisone
- ipratropium bromide via nebuliser oOral amoxicillin
And
- Identify and explain
- The specific nursing responsibilities associated with administering each medication and monitoring Neville for expected, side and adverse effects
Task 4: Patient teaching
During Neville’s hospital admission, it is part of the nurse’s role to review his current knowledge and understanding related to his condition and to update or provide new information.
Topics that need review/updating or new information are:
- How to effectively use a metered dose inhaler (MDI) and spacer
- Why he needs to stop smoking
- Early indicators that his COPD is deteriorating that require medical review
- Promoting adequate nutritional intake to meet his metabolic needs
- Energy conservation strategies
Identifythe specific information you will need to explain to Neville about the topic
And
- Explain
- Why the topic is an important aspect of Neville’s care
- How you will ensure that Neville knows and understand why it is important and, if appropriate to the topic, what he needs to do
Task 5: Clinical judgement and handover
There are two parts to Task 5.
Part A:
When you come back from your meal break, a colleague tells you that they have given Neville a prn salbutamol nebuliser as he requested it because he was short of breath.
The first thing you do is to check on Neville to find out if his breathing is more comfortable now. On checking Neville you notice:
Neville is
- Restless, anxious and mumbling incoherently
- Plucking randomly at his bed linen
- Dyspnoeic and, his
- Skin is flushed and diaphoretic and
- Nasal prong oxygen is still in place
On further assessment you find:
- Oxygen saturations are now 98% on nasal prong oxygen @ 2L/min
- Heart rate elevated to 110 beats/minute
- Respiratory rate has dropped to 8-10 breaths/minute
- The nebuliser mask and tubing is connected to the oxygen outlet
- Identify
- What you think is happening
- Your immediate nursing actions and interventions oThe reason for your actions and interventions
Part B:
An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.
Once Neville’s condition has been stabilised, the doctors arrange to transfer Neville to the High Dependency Unit for bipap and closer monitoring.
Using the ISBAR format, information from the handover you initially received and the additional information above:
- Write a handover that clearly and succinctly outlines the important information the high dependency unit needs to know about Neville
Your handover must:
- Demonstrate person-centred care
- Adhere to the legal and professional standards for documentation
- Be in appropriate professional language
- Contain NOabbreviations or nursing jargon
Answer:
Task 1: Understanding nursing problems
Ineffective airway clearance:
The patient under consideration has been admitted to the health care facility due to a chronic case of obstructive pulmonary disorder. In this disease hyper secretion of mucous from the goblet cells due to excessive exposure to cigarette smoke causes accumulation of cough and sputum in the bronchial airways (Donner & Carone, 2006). The inflammatory immune response to the excessive noxious particles due to disables the ciliary transport that is responsible for airway mucous clearance causing airway blockage.
Impaired gas exchange:
Impaired gas exchange in clinical terms can be described as the deficit of excess in the oxygen supply or carbon dioxide elimination in the respiratory airways, specifically in the alveolar-capillary membrane (Roche et al., 2013). Passive diffusion between the pulmonary capillaries and the alveoli facilitates the successful exchange of oxygen and carbon dioxide in the respiratory system. COPD and repercussions of excessive smoking can cause severely distressful conditions that cause the collapse of alveoli-capillary barrier and impair gaseous exchange in turn.
Risk for impaired ventilation:
The successful air ventilation within is facilitated by the passive diffusion of the oxygen and carbon dioxide across the alveoli-capillary barriers. Faulty gas exchange and mucous accumulation in the air ways can cause severe damage to the ventilator perfusion balance and cause impaired ventilation (Roche et al., 2013).
Imbalanced nutrition:
Neville is suffering from COPD coupled with dyspnoea that can make swallowing and chewing difficult. Apart from that extreme mouth breathing and coughing can also alter food taste and cause extreme fatigue in the patients which leads to faulty food intake and imbalanced nutrition (Loerbroks et al., 2012).
Risk for infection:
Excessive mucous production and accumulation in the respiratory tract can become the breeding ground for a multitude of bacteria and can lead to severe pulmonary and extra-pulmonary infection in Neville (Donner & Carone, 2006)
Task 2: Care planning
Nursing Care Plan: Neville
Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer
A reminder that all information must be referenced
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Nursing problem: Ineffective airway clearance
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Underlying cause or reason: Blocked airway due to increased mucous secretion
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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§ The patient is cleaned and properly dressed § The patient has cleared airways and can breathe properly.
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§ Dressing the patient is clean and dry hospital clothes. § Assessing airway for any resemblance of abnormal breathing sounds. § Teaching Neville the right manner fro coughing to help clear the airway naturally. § Educate the patient about optimal positioning technique and muscular use during coughing (Weldam et al., 2017) § Positioning the patient upright and performing nasotracheal suctioning § Maintenance of humidified oxygen for the patient as directed by the doctor (Kennedy, 2011). § Encouraging the patient to elevate the fluid intake by 3 litres and administering the prescribed medication. § Keep the patient in a warm environment.
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§ Clean and hygienic practice will help the patient feel comfortable and help in his recovery. § Maintaining the respiratory airway patent is the first priority in case of chronic obstructive pulmonary disorder (Loerbroks et al., 2012). § The most convenient method to remove airway secretion is through coughing the deeply through mouth putting necessary pressure (Kennedy, 2011). § Optimal sitting positioning and abdominal splinting while coughing generates more [pressure for the cough to come out through mouth by upward diaphragmatic movements. § Nasotracheal suctioning is a vital technique to be used when the patient cannot cough out the secretions on his own (Ray & Barger Stevens, 2013). § Humidified air when inspired can aid in reducing the thickness of the secretion and help in removal. § Keeping the patient well hydrated will stop the mucous from drying out. § Prescribed medication will aid in cleaning out the airway (Weldam et al., 2017). |
§ The patient is responding to the interventions. § The patient can breathe with lesser effort. § The abnormal breathing sounds are decreasing. § The patient is well hydrated and comfortable. |
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Nursing problem: Impaired gas exchange |
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Underlying cause or reason: Inaffective airway clearance and poor ventilator functions |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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§ The patient is warm and comfortable § The patient has revived successful gaseous exchange.
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§ Assessing and documenting the respiratory rate and oxygen saturation. § Positioning the patient in semi Fowlers position. § Administering the maintaining the humidified oxygen device. § Encouraging slow deep breathing using a spirometer (Odencrants, Ehnfors & Grobe, 2007). § Provide suctioning and administering the medication § Keep the patient in a warm and comfortable environment
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§ Upright positioning of the patient will allow lung expansion and increased diaphragmatic activity. § Continuation of humidified oxygen will ensure that the mucous accumulation is diluted and the airway is being progressively cleaned (Ray & Barger Stevens, 2013). § Slow breathing increases the oxygenation and avoids the risk of atelectasis. § Suctioning and medication will help in clearing the airway and revive ventilation perfusion balance (Odencrants, Ehnfors & Grobe, 2007). |
§ The patent reduces shallow forceful breathing § The patient looks visibly better § The patient feels lesser fatigue and is warm and comfortable. § The patient uses lesser muscular strength while breathing
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Nursing problem: imbalanced nutrition, lesser than the body requirements |
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Underlying cause or reason:
Fatigue and loss of appetite due to dyspnoea, mouth breathing, coughing and excessive medication |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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The patient is well fed and well hydrated.
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§ Checking the body weight for the patient § Provide healthy and hygienic food items rich in vitamins, minerals and antioxidants (Odencrants, Ehnfors & Grobe, 2007). § Encourage the patient to sit upright while eating. § Encouraging the patient on healthy liquid diet. § Incorporating rest periods for the patient between meal times. § Practicing diligent oral care and dental hygiene. |
§ Food items infused with antioxidants will boost up the immune system in the patient and reduce the fatigue (Odencrants, Ehnfors & Grobe, 2007). § Upright positioning will eliminate the risk of aspiration. § Resting in between meal times will allow the patient to build up energy to take the amount of food required for him (Valente et al., 2012). § Practicing oral hygiene will improve appetite and the taste of the food
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§ Visible improvement in the appearance in the appearance of malnutrition. § Considerable education in the fatigue of the patient § Marked increase in the appetite of the patient. |
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Nursing problem: risk of infection |
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Underlying cause or reason:
Accumulation of cough and sputum in the airways |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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The patient is safe And overcomes any risk of infection.
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§ Clearing the respiratory airway of the patient. § Periodic suctioning of the airways to keep the airway cleaned at all times § Maintaining diligent oral hygiene with chlorehexin (Weldam et al., 2017) § Incorporating breathing exercises and sterilize the patient periodically |
§ Suctioning will clean out all the excess mucous that the bacteria feed on § Oral hygiene using an antimicrobial agent like chlorehexin will ensure that the microbial population in body is minimal (Mueller et al., 2017). § Breathing exercises will help in keeping the tract clear. |
§ The pathological test of the mucous is not alarming § No visible signs of infection in the patient § The patient condition continues to improve |
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Nursing problem: increased fatigue in the patient |
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Underlying cause or reason:
Severe COPD with deep coughing and worsening dyspnoea coupled with decrased appetite |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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The patient is well rested
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§ Relieve the existing grievances of the patient § Maintain a strict diet plan for the patient § Arrange for extensive resting periods for the patients § Continue feeding the patient antioxidant rich diet (Kennedy, 2011). |
§ Allow the patient relive from all the suffering so that the patient can relax § Increased appetite and good diet will increase the eliminate signs of malnutrition § Extensive rest and antioxidant rich diet will eradicate fatigue levels (Weldam et al., 2017) |
§ The patent improve the physical strength § Appetite returns § The patient can move on his own § The patients tires out lesser and lesser as the treatment progresses. |
Task 3: Medication management
Oral prednisone:
Prednisone is a respiratory distress medication belonging to the group of corticosteroid drugs. Oral corticosteroid drugs are prescribed in COPD as it is exceptional in decreasing the inflammation in the respiratory airways and reducing the excessive secretion of mucous. This medication is tremendous in improving lung functions and reduces the risk of endotracheal incubation in the patients hence is prescribed in case of severe COPD (Rosenberg, 2011)
Ipratropium bromide via nebuliser:
Ipratropium bromide is a bronchodilator and is used to dilate the airways and is a integral medication for treatment of COPD. This medication acts as the inhibitor of acetylcholine effect of cholinergic nerves on the bronchial airways and revives the ventilation balance in the patient (Ferguson Gt, Dai & Dunn Lj, 2013). This medication is mostly available in liquid form and is prescribed via a nebulizer for Neville as a nebulizer changes the liquid into a spray that travels directly to the airways and is not absorbed too much in the body.
Oral amoxicillin:
Amoxilin is an antibiotic that is prescribed in case of COPD to reduce the risk of infection in the respiratory tract that can complicate the condition of the patient further. Taking a broad spectrum antibiotic will reduce the risk of Neville experiencing acute exacerbation or COPD flare ups that are generally caused due to infection (Mueller et al., 2017).
Nursing precautions and side effects:
- Corticosteroids can affect the blood glucose levels so the nursing professional must ensure to check the blood glucose levels o the patient (Prazma et al., 2017).
- It can have a repercussion involving urinary functions of the patient so it necessary for the nurse to ensure that the patient is in low salt diet or in a high potassium diet.
- Inhalation of bronchodilators through a nebulizer can cause drying and irritation of throat and mouth, hence the nurse assigned to Neville must ensure that the patient takes sips of water and either rinses and gargles after each administration (Ferguson Gt, Dai & Dunn Lj, 2013)
- Amoxicilin can cause nausea and vomiting in the patients as well.
Task 4: Patient teaching
A metered dose inhaler (MDI) and spacer is an important clinical tool for the patients dealing with chronic obstructive pulmonary disorder (Ehtezazi et al., 2010). It is imperative that the patient understands how to properly use the device to ensure that he can use in times of need.
The correct manner to use an inhaler device is to shake the device properly, remove the cap and place the inhaler into the spacer. Next the patient has to breathe away from the spacer and then bring the spacer near mouth and put the mouthpiece of the MDI between his upper and lower teeth. The patient is then advised to slowly breathe in and hold it for ten seconds briefly and then breathe out slowly. It is imperative that the patient breathes slowly, if hearing a whistling sound, it indicates the patient is breathing too fast, it is advised to slow breathing down at that point. The patient will also be need to be educated on how to clean the MDI properly and all the precautionary measures like sipping water and rinsing the mouth after each use (Ehtezazi et al., 2010).
I would demonstrate the right manner to use a metered dose inhaler and educate him how to use the spacer. Moreover I will ensure teaching him how to clean a MDI as well and carefully educate him about all the safety precautions. I will ensure his clear understanding on the administration and claiming procedure using ask-tell-ask approach.
Task 5: Clinical judgement and handover
Part A:
Salbutamol, being a β agonist drug also reacts to corticosteroid medication and causes symptoms of tremor, restlessness, incoherence, shortness of breath and myocardial contractions (Lima et al. 1999). The patient in this case was experiencing a strong hypersensitivity reaction to salbutamol after being on oral prednisone which is a corticosteroid, and without immediate action the patient has the risk to cardiac arrest.
The nursing intervention at this point should focus on anaphylaxis and adminstrtaion of epinephrine (Kennedy, 2011). It will aid in decreasing the hypotension reaction in the patient and will help in stabilizing him.
Task B: Nursing handover:
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· Neville, 62 year old, male |
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· This handover is to mention that Neville has been stabilized after his hypersensitivity reaction to salbutamol after taking oral corticosteroid and is to be taken into high dependency unit for BIPAP and for close monitoring.
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O |
· Neville has been admitted to the facility due to moderate to severe COPD and was exhibiting symptoms of ineffective airway clearance, impaired gas exchange, imbalanced nutrition and impaired ventilation. · Medical concerns regarding him is infection causing relapse and the extreme reaction to salbutamol he experienced. |
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B |
· Neville is 62years old · He has been admitted because of his moderate to severe COPD coupled with acute Dyspnoea · He had a long history of smoking and upon admission had all signs and symptoms of acute COPD and was tachycardic with high blood pressure · His treatment included airway clearance and oral prednosine, Ipratropium bromide via nebuliser and Oral amoxicillin till date. |
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· His current condition has been all signs of approaching cardiac arrest due to reaction to corticosteroid and β-agonist. · The medical concern to his condition remains the risk he is in to infection and the chance of his reaction getting more severe. · I have performed manual and suction cleaning of his airway and have kept him in antioxidant rich liquid diet along with periodic administration of the medication prescribed to him.
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· I need you to review the patient for any chance of relapse and infection in his respiratory tract and ensure the patient does not revert back to imbalanced nutrition as he has been suffering with extreme fatigue. · Apart from that keep the patient well hydrated and monitor his vitals for BIPAP and other assessments.
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References:
Donner, C., & Carone, M. (2006). Clinical Challenges in COPD (Clinical Challenges). Oxford: Atlas Medical Publishing.
Ehtezazi, Saleem, Shrubb, Allanson, Jenkinson, & O’Callaghan. (2010). The Interaction Between the Oropharyngeal Geometry and Aerosols via Pressurised Metered Dose Inhalers. Pharmaceutical Research, 27(1), 175-186.
Ferguson Gt, Ghafouri M, Dai L, & Dunn Lj. (2013). COPD patient satisfaction with ipratropium bromide/albuterol delivered via Respimat: A randomized, controlled study. International Journal of COPD, 2013(Default), 139-150.
Kennedy, S. (2011). Caring for a patient newly diagnosed with COPD: A reflective account. Nursing Standard (through 2013), 25(49), 43-8.
Lima, John J., Thomason, Donald B., Mohamed, Mohamad H.N., Eberle, Louis V., Self, Timothy H., & Johnson, Julie A. (1999). Impact of genetic polymorphisms of the [beta].sub.2 -adrenergic receptor on albuterol bronchodilator pharmacodynamics. Clinical Pharmacology & Therapeutics, 65(5), 519.
Loerbroks, Adrian, Jiang, Chao, Thomas, G., Adab, Peymané, Zhang, Wei, Lam, Kin-bong, . . . Lam, Tai. (2012). COPD and Depressive Symptoms: Findings from the Guangzhou Biobank Cohort Study. Annals of Behavioral Medicine, 44(3), 408-415.
Mecklin, Minna, Paassilta, Marita, & Korppi, Matti. (2012). Salbutamol with metered dose inhalers with spacers – an established emergency treatment for preschool wheeze.(Report). Acta Paediatrica, 101, 1161.
Mueller, Wilke, Bechtel, Punekar, Mitzner, & Virchow. (2017). Non-persistence and non-adherence to long-acting COPD medication therapy: A retrospective cohort study based on a large German claims dataset. Respiratory Medicine, 122, 1-11.
Odencrants, S., Ehnfors, M., & Grobe, S. (2007). Living with chronic obstructive pulmonary disease (COPD): Part II. RNs’ experience of nursing care for patients with COPD and impaired nutritional status. Scandinavian Journal of Caring Sciences, 21(1), 56-63.
Prazma, Wenzel, Nelsen, Gunsoy, Cockle, Albers, . . . Yancey. (2017). Perception of oral corticosteroid side effects in patients with corticosteroid-dependent asthma. The Journal of Allergy and Clinical Immunology, 139(2), AB96.
Ray, Shaunta M., & Barger Stevens, Amy R. (2013). Choosing the right inhaled medication device for COPD.(Editorial). American Family Physician, 88(10), 650.
Roche, Nicolas, Chavannes, Niels H., & Miravitlles, Marc. (2013). COPD symptoms in the morning: Impact, evaluation and management. Respiratory Research, 14, 112.
Rosenberg, J. (2011). Lack of pretreatment cost-effectiveness and side effects of omalizumab versus prednisone/montelukast on tolerability of immunotherapy. Journal of Allergy and Clinical Immunology, 127(2), 548.
Teixeira, Lopes, Martins, Diniz, De Menezes, & Alves. (2016). Validation of Clinical Indicators of Imbalanced Nutrition: Less Than Body Requirements in Early Childhood. Journal of Pediatric Nursing, 31(2), 179-186.
Valente, M., Moura, E., De Oliveira Lopes, M., De Castro Damasceno, A., & Evangelista, D. (2012). Clinical Indicators of the Nursing Diagnosis of “Imbalanced Nutrition: More than Body Requirements” in Pregnant Women. Public Health Nursing, 29(3), 276-282.
Weldam, Lammers, Zwakman, & Schuurmans. (2017). Nurses’ perspectives of a new individualized nursing care intervention for COPD patients in primary care settings: A mixed method study. Applied Nursing Research, 33, 85-92.
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