University of San Jose- RecoletosCollege of Nursing

Cebu City

A FAMILY CASE STUDY OF

ASTHMA

In Partial Fulfillment of the Requirement in NCM 102-RLE

Family Health NursingBarangay QuiotFirst Rotation

December 5,2009

Presented to the FacultyOF

University of San Jose – Recoletos

Submitted to

Mr. Dormedo de Lara

Date

December 5, 2009University of San Jose- Recoletos

College of Nursing

COMMUNITY HEALTH NURSING(Family Case Study (Level II)

I. Introduction:

GENERAL INFORMATION

1. Historical Background In 1928, early settlers named their place Barrio Kiyot, derived from a name of a insect very common in the place that used to stay in Mayupay and bamboo tress. During that time, Teodoro Rago was the Kapitan for the owned the biggest land area. However, it was Gregorio Ylaya who became the first Teniente del barrio.

Early families who settled in barrio Kiyot were Ambrosio Abellanosa, Frankelina Sabandeja, Pedro Abellanosa, Luis Llamedo, Mariano Bacalso, Pastor Sabandeja, Nicolas Sabandeja, Estiban Cabarubias, Fernando Pañibon, Santiago Cabaluna and Maximo Sadura.

In 1952, Maximo Daculan ruled the barrio. Other leaders after his term were Melicio Obenieta [3rd teniete del barrio], Ricardo Llamedo [4th tiniente del barrio].

In 1957, barrio Kiyot was recognized officially as a Barangay.

Other officials who have served Barangay Kiyot were Barangay Captains Tereso Canares in 1972, Celso Diaz in 1982, and Vicente Sabarre in 1988, Attorney Sañara succeeded in 1990 to August 15,2002 and Hon. Vicente B. Ramos,Jr.Take over August 15.2002 whom until now is the Barangay Captain.

Then the youth sector convincing changed the spelling of Kiyot to Quiot.

2. Physical Characteristics

2.1 Geographic Location

Barangay Quiot is a relatively small Barangay of Cebu City with total land of approximately 32 hectares. Bounded by the Barangay Basak, Pardo in the North, Basak Pardo in the East, Toong in the West and Kinasang-an Pardo in the South.

The Barangay is composed of 32 Sites namely Quiot Proper, Qyda, Kmayupay, Kawayan, Bahanihan, UBCA-I, UBCA-II, UBCA-III, Kalubin, Kalubihan, Honey Ville, Murillo, Bakilid, Bogo, Genes I & II, Ediang, Lantawan, Kilis, Antuanga, San Carlos Heights,Suran, upper Suran, Greenbelt, Mountain View, Lower Yati, Uper Yati, Granada, River Siade, Beltran, Back Japer, Sto. Niño and Kamansi.2.2 Topography

The terrain of the areas has rugged hillside, which varies from steep in the upper portion and rolling slope in the rolling portion. The area lies at an elevation 200 to 300 meters above the sea level with a slope 18 to 13 %.

2.3 Climate and Weather

Two climatic conditions characterize the area dry in the months of January to May and wet from June to December.

2.4 Geology and Soil Condition

Geology formation in Barangay Quiot is serpentinized peredotite. Its soil condition is Faraon clay, which is rich in organic matter highly calcareous.

3. Socio-Economic Conditions

3.1 Social3.1.1 Demography

Based on the Barangay Family Profile Census, Barangay Quiot has a total population of 18,556, of which 9,397 compromises the male while 9,159 compromise the female.

Approximately, there area 2,470 household with an average of 6 members per family living in the Barangay.

3.1.2 Livelihood

It is estimated that 60% of the population ore government and private employees, contract workers, and self-employed. Others are engaged in business.

3.1.3 Health

Basic health services in the area are well provided by the Barangay health center personnel. The center has Health Workers, Physician, Midwife, Nurse, Dentist, and Health Worker Trainees who provide daily health services to its residents in the Barangay.

Barangay Health record shows that the Eleven leading causes of mortality are: cancer, pneumonia, TB pulmonary, CVA, Hypertension, myocardial infarction, liver cirrhosis, Diabetes Mellitus, peptic ulcer disease, sepsis and status asthamaticus. [Refer to the table below.]

Table 1. Eleven Leading Cause of Mortality in Barangay Quiot

As of 2009, The Nutritional Status of Health was the following: Normal 1,708 = 68%, Underweight 635 = 25%, Chronic Mal Stunting 37 = 1.48%, wasting (acute) 1 = 0.04% and over weight 115 = 5%. Nutritional status monitored on monthly basis by our Barangay health personnel.

3.1.4 Education and Manpower

At the present there does exist primary school and no secondary schools in the area. However, the Barangay is accessible to the university to the University of San Jose Recoletos Basak Campus, Basak Elementary School, Pardo Elementary School, Holy Rosary High School and Gulas High School. There is an existing Day Care Center located in the UBCA Sports Complex and two Private Day Care Centers run by Sacred Heart of Mary Sisters and A-Z Scholar run by the Born Again Christians.

3.1.5 Housing

Almost 50% of the Barangay residents are living in dwellings made of light materials like coconut lumber, nipa and bamboo. 30% of the houses are semi-concrete and 20% are concrete. There are also several subdivision within the area.

3.1.6 Social Services

The Day Care Workers in the Barangay is giving services to 80 preschool children with 48 boys and 32 girls. Classes are being held in the Day Care Center located in UBCA.

Causes Number of DeathsCancer 12Pneumonia 12TB pulmonary 8CVA 7Hypertension 7Myocardial Infarction 7Liver Cirrhosis 2Diabetes Mellitus 2Peptic Ulcer Disease 2Sepsis 2Status Ashmaticus 2

3.1.7 Protective Services

The Police population ratio in the area is 1: 3400. The Barangay has been request 1 regular PNP to coordinate with the Barangay Tanod Peace and order operation similarly augment or assist in the delivery of protective services. The existing two mobile cars are utilized in the peace and order operation conducted by the Barangay Tanod Personnel. Pardo Police Precinct and Punta princesa Police precinct 10 is the nearest Police station.

3.1.8 Sports and Recreation

The Barangay has 1 Sports Complex, the venue for various sports and cultural activities. Interior sitios have their own basketball courts. One of the highlights in sports during summer is the holding of inter-sitio Summer League.

3.1.9 Religious Services

Majority of the residents in Barangay Quiot is Roman Catholics. Others are Protest and Born Again Christians.

3.1.10 Economic

Based on the Department of Trade and Industry Cebu Provincial Office Directory – Registered Business Names By type/sector in 2002, residents of Barangay Quiot are engaged in various commercial activities. These include bakeries, General Merchandise, figurines, aggregates, frames, construction supply and religious articles.

4. Infrastructures and Utilities

4.1 Power

The Visayan Electric Company is providing power services in the whole Barangay.

4.2 Communication

Almost all types of communication facilities are present in the area such as cellular phones, telephones [ISLAPHONE], handset radio. Television, radio sets, etc. there are also telefax counter and telephone booths manned by various communication companies. The Philippines Postal Corporation also services the Barangay.

4.3 Transportation

Access to the area is through public utility vehicles, taxi, motorcycle, tricycle and other means of land transportation via three routes. Highway, Punta Princesa and Pardo.

4.4 Water

The Metro Politan Cebu Water District has provided water services in the barangay. There is an existing natural spring, which is one of the water sources in the area. Three other private deep well supplies around fifty 75% of the total households. One of this is the Sitio Genes Compound while the rest is servicing Sitio UBCA and Sitio Mayupay, San Carlos Heights, Granada and Greenbelt respectively. There is an on going Water Project of the Barangay tapping lower Antuanga source to upper Antuanga for distribution to the Barangay via gravitational force.

5. Land Classification

The uppermost north portion of the Barangay is classified as timberland. However most areas are classified as alienable and disposable. A private person owns about 40% of the total land area of the lower portion of the Barangay.

6. Existing Land Use

Fruit-bearing trees like coconut, jackfruit are planted on the hilly land portion of the Barangay. There are Mahogany and G’melina species planted along the Barangay road. Residential use is also evident.

II. Rationale of the Family Case Study

Why did we chose Sitio Qyda?

Of all the Sitio in Barangay Quiot, we chose Sitio Qyda (Quiot Young Dreamers Association) as our prioritized Sitio in part of our related learning experience in Community Health Nursing. We chose this Sitio because e observed that people living in the Sitio has different problems which needs an immediate action. The place is one of the depressed areas among the Sitio in Barangay Quiot. A crowded place where houses are built close to each other which are made of light, mixed and concrete materials which is the primary cause of fire. We also observed improper drainage system and most of them are stagnated because of the plastic that is stucked in the canals which can be a breeding site of vectors of diseases. According to the Nurses in the Helth Center, Barangay Quiot is one of the Barangay’s that has an increased number of cases of dengue and with our Nursing Interventions, we could help minimized these cases.

Why did we chose Brosas’ family?

We chose Brosas’ family in our case study because they need more of our nursing intervention. As their existing problem is known to be genetically inherited, we want to trace some genetic variants that can trigger asthma. Also we want to intervene these that affects their health. Their surroundings is known to be a breeding sites of vector of disease because of its open drainage, garbages that clogged on it. Risk for pulmonary disease that includes asthma

because of the factory near the site that trigger asthma because of the polluted air it release.

III. Objective:

General:

The client will be able to know the different causes of Asthma. Create an environment that can lessen the allergens of Asthma. Promote ventilation in their house. Avoid extrinsic allergens of Asthma.

Specific:

The client will be able to know how to provide immediate care of Asthma attack. To know the advantages of different medications prescribed by their Physician. To know the different preventive measures for Asthma. The student nurse will be able to know the different aggravating factors of

Asthma and it’s effects on the body. To know the Signs and Symptoms of Asthma. To know how to relieve the signs and symptoms of Asthma. To enhance the student’s capability in providing care of an Asthmatic patient. For the client to know the complications of Asthma. To know and identify what triggers Asthma.

IV. Family Assessment:

Normal Findings Actual Findings1. General Health Survey a. Weight 3-5 lb. (1.3-2.2 kg) 18 kg b. Height 1-2 in. (2.5-5 cm) 91 cm c. Vital Signs c.1.Temperature 37.3 Celcius c.2. Pulse 70-80 bpm 87 bpm c.3. Respiration 24cpm c.4. Blood Pressure 112/60 mmHg 70/30 mmHg2. Integumentary a. Skin Texture Skin intact, no lesion Presence of scars, dry skin b. Hair Evenly distributed, no

pediculosisEvenly distributed hair; no lesions, no dandruff and absence of pediculosis

c. Nails Concave Concave, pinkish, CRT for 2-3 seconds

3. HEENT Head/Neck Head size becomes more

proportionate to the body Eyes V.A. should be 20/20 by age Eyes are symmetrical, sees

6 the ball of 20ft distance Ears Hearing intact, tympanic

membrane intact; no drainage

No drainage, able to recognize high pitch and low pitch sounds

Nose Nasal mucosa pink and intact.

Absence of any fluid secretion, nasal mucosa pink

Throat/Mouth Tonsils are usually large; oral musosa pink, no lesions. Child loses first teeth during these time.

Presence of dental caries, tonsils are large, absence of lesions in oral cavity

4. Respiratory Lungs clear R.R: 24 cpm, absence of wheezing and crackles

5. Cardiovascular Regular rhythm, no extra sounds

P.R:87 bpm, no extra sounds detected such as murmurs

6. Gastrointestinal Abdomen soft, non-tender, no organomegaly

Abdomen is soft, non-tender, no mass found out

7. Urinary External genetalia intact, appropriate development for child’s age

Absence of pain during urination, yellow color of urine, no blood or no other color seen.

8. Reproductive External genetalia intact, appropriate development for child’s age

9. Musculoskeletal Normal curves noted, no abnormalities, no weakness

10. Neurological Balance and coordination greatly improved; with refinement of fine motor skills

a. Cranial Nerves a.1.Olfactory Identified the substance Able to identify the coffee a.2.Optic Visual acuity intact 20/20

OU a.3.Oculomotor PERRLA direct and

consensual a.4.Trochlear a.5.Abducens a.6.Trigeminal Client perceives light touch

and superficial pain bilaterally

Perceived the cotton bilaterally

a.7.Facial Able to make facesTaste sensation on anterior tongue

Able to perform facial expressionsTasted the coffee in the anterior tongue

a.8.Acoustic Hearing intactNegative Romberg’s Test

Able to respond and didn’t lost his balance

a.9.Glossopharyngeal Taste on posterior tongue intact

a.10.Vagus Swallow and cough reflex intact

Able to cough out and swallow

Speech clear a.11.Accessory Moved against resistance

without painMoved against resistance without pain

a.12.Hypoglossal Can protrude tongue medially

Able to move tongue medially and bilaterally

V. Physical Assessment/Examination – Gordon’s – (Family)

Gordon’s Functional Pattern

1. Health Perception - Health Management Pattern

I. Client's Perception of Health

The client says that he is healthy but he has a little problem because of his asthma and due to this problem, he rated his health as 8 out of 10. He also said that the most important thing to keep him healthy is to eat proper diet with regular exercise, and that would the clients’ perception of health.

II. Client's Perception of Illness

Because of the clients’ asthma problem, he feels uncomfortable because he has this breathing problem. The clients’ daily activities are not affected because he has maintained a treatment. The client said that he got his asthma problems in their genes in the paternal side, which mean hereditary. The client strongly believes that with following the doctor’s prescription, proper intake of medicines and doing regular exercises, his illness will be treated.

III. Health Management and Habits

The clients consults to a private doctor every time he feels that there something wrong with his health accompanied by his parents, but with no exact schedule. He considered playing as means of exercise. The clients went often for dental check up every 2 months. "I believe that eating the right kind and the right amount of food makes u healthy in partnership with regular exercise and proper hygiene as well”, as verbalized by the patient. He also believes that doing nothing contributes

to illness because you have to keep our self busy to make our life healthy. The patient doesn’t perform any self-exams and not even use alcohol, tobacco drugs and caffeine as he believes that he wont get a good benefit as form it.

IV. Compliance with Prescribed Medications and Treatment

The client have been taken his prescribed medication at the right time without refusing the doctors ordered. The client has been following the doctors prescribed nursing and medical treatment such as doing the exercise regularly and eating the right amount and the right kind of food, which are good to me. Yes its been easy for me to carry the doctors ordered and suggestion through the supervision of my parents.

2. Nutritional- Metabolic Pattern I. Dietary and Fluid Intake

The clients eat three times a day of what the parents do give to him such as food which can be easily cooked or sometimes vegetable and fish but not often. Her mother feed him foods which can be easily bought and cooked in the sari -sari store such as can goods and noodles and doesn’t follow a certain type of diet because what food is easily seen and easily bought by her mother it will be the one to cooked. The patient doesn't find any difficulties when regards to eating the meals on time because he eats his meal three times a day at 7in the morning for breakfast, 12 in the afternoon for lunch and 6 in the evening for dinner. "I just take my snacks at school during recess time with crackers and juice and I don’t take any herbal supplements", as verbalized. The client drinks water every time he feels thirsty with 3-4 glasses a day and doesn’t find any difficulties in chewing or swallowing the food. He also stated that he has no allergy for a certain kind of foods.

II. Metabolism

The client stated that he gain weight, from 16 it becomes 18 after he had a check-up with a doctors clinic. He can only notice if he has gain weight through his body size without using any instrument. The client stated that, "so far, I haven’t notice any changes in my eating habits as well as my drinking habits.

Objective data: Temperature: 37.3 celcius Pulse: 87 bpm Respirations: 24 bpm Height: 91 cm Weight: 18 kg

3. Elimination Pattern

I. Bowel Habits

The client usually moves his bowel 2 times a day with a light brown color and soft consistency of the stool and doesn’t notice any recent changes of his bowel

pattern. He stated that he usually postponed defecation when he is not home because his feeling not comfortable defecating to others comfort room. The client stated that he haven’t experience constipation and diarrhea and doesn’t do anything special to treat or prevent problems with voiding and haven’t had a bowel surgery as well.

II. Bladder Habit

The client usually voids 6-8 times a day with light yellow color urine with no bleeding present or any abnormalities found. The client stated that “I haven't experienced or encounter any problem during urination, such as UTI” as verbalized. In addition, he hasn’t experience yet inserting a urinary catheter.

4. ACTIVITY-EXERCISE PATTERN

I. Activities of Daily Living

The client usually walks on his way to school, which is approximately 2 km away from his house. Since he is a seven-year-old child, he usually plays with her younger sister in their backyard. Her younger sister is also asthmatic and they feel restless easily. Sometimes, they experience difficulty in breathing after a prolonged time in playing especially stressful games.

II. Leisure Activities

The client is fond of playing with his toy car in their yard with his sister and they also watch movies or shows together or sometimes, with their parents.

III. Exercise Routine

He walks regularly to school and play with his friends

5. SLEEP AND REST PATTERN

I. Sleep Habits

Since his class is at 1 o'clock, he usually wakes up at 8 am and sleep at about 7 pm and reported that most of the time, he has a sound sleep but when there is an asthma attack, it is really difficult for him to sleep.

II. Sleeping Aids

He does not use any medications or pills to fall asleep but he cannot sleep when it is so hot and needs the aid of the electric fan.

6. COGNITIVE- SENSORY- PERCEPTUAL PATTERN

I. Perception of Senses

As of now, the client is not suffering from any impairment and he can use his senses very well but during colds, it is very difficult or him to use his sense of smell.

II. Pain Assessment

As we go through with our assessment, the client does not complain of any tenderness of we cannot observe any guarding behavior but during asthma attack, he complains of chest pain and considers breathing as a hassle. The pain is relieved when he tries to minimize breathing.

III. Ability to understand

The child can understand some of our questions but sometimes, he is too shy to answer but generally, he quite understands and can comprehend our questions.

IV. Ability to Communicate

So far, as a seven-year-old child, it is so hard for him to remember his medications and understand why he is taking such medications.

V. Ability to remember

We asked him about his previous hospitalization and he could still remember it and he could even recognize the hospital and he could also remember the reason for the hospitalization.

7. SELF-PERCEPTION-SELF-CONCEPT PATTERN

I. Perception of Identity

Unfortunately, for a child, playing is very important for his development and socialization and feel a sense of belongingness but for him, he is an ill child and gets tired easily so, he perceive himself as a loner and a home-buddy.

II. Perception of Abilities and Self- worth

He considers his parents as his strengths and considers his illness as his weakness and a burden for his childhood

III. Body Image

He may not be that active in physical activities because of his illness, he still consider himself lucky compared to those people who are amputated or people with disabilities.

8. ROLE-RELATIONSHIP PATTERN

I. Perception of Major roles and responsibilities in the family

As an eldest child, it is his responsibility to look for her younger sister when their parents are not home but he is still seven years old and he cant realizes its

significance yet. And usually, they experience sibling rivalry and he feels that all the blames were always put into him. With the people in their community, he is not so close to other children because he just goes out of their house really often and also, because of his illness that he was not able to spend time with them.

Family Genogram:

Legend:

Female

Male

Deceased

Client

Ivy Bros

as

29 y.o.

Cricencia Castr

o

50 y.o

Jovito Castro52 y.o

HB

Odisa30 y.o.Asthm

a

Olivia26 y.o.Asthm

a

Perpecto28 y.o.A&W

Driver

Dennis Brosas

34 y.o.Asthma

Rosalia

Brosas

60

A&W

Henry Brosas65 y.o.Asthma

Anna Victo

ria

3 y.o.

Dave3 y.o.Astma

9. SEXUALITY- REPRODUCTIVE PATTERN

Since the client is still seven years old and he is still not in the pubertal stage, it is impossible for him to engage in any sexual intercourse based on his behavior and physical appearance. When we asked him if he is ready for puberty, he just answered with a smile and said that it’s still so early for it.

10. COPING AND STRESS TOLERANCE PATTERN

I. PERCEPTION OF STRESS AND PROBLEMS IN LIFE

For him, his illness is really one of the factors that can worsen the stress in school specially when they have assignments and yet he could not do it suffering from an asthma attack.

II. Coping methods and support systems

In his age, he is much closer to his mother than with his friends so, when he feels depressed, he just goes to his mom and cry. In his age, stress is really not the main problem but rather, emotional disturbance and bullying could be the reasons for the child's depression.

11. VALUE-BELIEF PATTERN

I. Values, Goals and Spiritual Beliefs

In this age the most important people in his life is his family or specifically his parents and his parents are the factors that influence him in decision-making and the source of his hope and strength.

II. Religious and Spiritual Beliefs

According to his parents, they do pray a lot when someone is ill or hospitalize and they let their child hold and pray the Holy Rosary.

VI. Anatomy & Physiology – Pathophysiology (sick Family Member)

Asthma is a chronic inflammatory airway disorder characterized by airflow obstruction and airway hyperresponsiveness to a multiplicity of stimuli. This widespread but variable airflow obstruction is caused by bronchospasm, edema of the airway mucosa, and increase mucos production with pluging and airways remodeling that it’s a type of chronic Obstructive Pulmonary Disease (COPD), along term pulmonary disease characterized by increased airflow resistant; other types of COPD include Chronic Bronchitis and emphysema.

CAUSES

Extrinsic allergens animal dander food additives containing sulfites house dust or molds ‘kapok’ or feather pillows other sensitizing substances Pollen

Intrinsic Allergens Anxiety Coughing and laughing Emotional stress Endocrine changes Exposure to noxious fumes Fatigue Genetic factors Humidity variations Irritants Temperature variations

Pathophysiology

Environmental factors interact with inherited factors to caused asthmatic reactions with associated bronchospasms in asthma bronchial lining over react to various stimuli, causing episodic smooth muscle spasm that severely constrict the airways. On subsequent exposure to antigen, mast cells degranulate and release mediators. Mast cells in the lungs interstitium are stimulated to release histamine and Leukotrienes. Histamine attaches to receptor sites in larger bronchi, where causes swelling of smooth muscles. Mucus membranebecome inflamed, irritated and swollen. The patient may experience dyspnea, prolonged expiration and an increased respiratory rate.

Leukotrienes attached to the receptor site in the smaller bronchi and can cause local swelling of the smooth muscle. Leukotrienes also caused prostaglandin to travel through the blood stream to the lungs, where they enhance the histamine’s effect. A wheeze maybe audible during coughing – the higher the pitch, the narrower the bronchial lumen. Histamines stimulates the mucos membranes to secrete excessive mucusto further narrow the bronchial lumen. Goblet cells secrete viscous mucus that is difficult to cough out resulting in coughing, rhonchi, increase pitch wheezing and increases respiratory distress. Mucosal edema and thicken secretions further block the airways. On inhalation, the narrow bronchi lumen can still expand slightly, allowing air to reach the alveoli. On exhalation, increase intrathoraxic pressure closes the bronchial lumen .

SIGNS AND SYMPTOMS Sudden dyspnea, wheezing and tightness in the chest Coughing that produces thick, clear or yellow sputom Tachypnea Rapid pulse Hyperresonant lung fileds from air trapping

Demenish breath sounds

DIAGNOSIS complete blood count chest x-rays arterial blood gas analysis

TREATMENT

MEDICAL INTERVENTIONS desensitization to specific antigens bronchodilators corticosteroids leukotriene modifiers and leukotriene receptor antagonists anticholinergic bronchodilators

NURSING INTERVENTIONS

Relaxation exercises like yoga to increase circulation and help the patient relax and relieve stress.

Identification and avoidance of precipitating factors (environmental antigens or irritants) to prevent asthma attacks.

Use a facemask to cover their nose and mouth to prevent them in inhaling the smoke or polluted air.

Educate the mother on the effects of the smoke from the factory to her family’s health.

VII. Prioritize of Health Problem

VIII. FNCP (Follow Format)IX. Conclusion

Therefore, base upon initial and periodic assessment and monitoring, avoiding extrinsic allergens that triggers asthma, appropriate pharmacologic therapy and enhancing the educational partnership should reduce the burden of asthma in the patient and their family as well. A family with an asthmatic member affects a person's activities of daily living and could be a burden during hospitalization, absence during school days and work days and also their restricted activities, which prevents the parson’s ability to achieve optimum functioning.

In our patient's case, asthma was not just genetically acquired because during our assessment, we observed different risk factors like the factory beside their house, open drainage, poor ventilation, and presence of allergens. With proper care, love and encouragement from his parents, he can live his life happily just like any other children.

X. Recommendation

Family is considered as the basic unit of the society. The person's ability as a social being starts at home with his/her family. Having an asthmatic member of the family is sometimes a burden specially that they are experiencing global economic crisis. Love, care and encouragement could help the child reach his optimum potential despite of

having such illness. A child with asthma also needs special attention not just emotionally but also medical check-ups and pharmacologic therapy is really needed to promote and prolong the child’s life.

XI. Bibliography

Maternal and Child Health Nursing (Care of the childbearing and childbearing family)Adelle Pilliteri Vol.2 Chapter 31

Nursing Health Assessment 2nd edition; Patricia Dillon Chapter 26

XII. Documentation