cf patient tshumway

8/18/2019 CF Patient TShumway

1/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

KAPI’ODURING CLINICAL:Complete the following pages for the patient assigned to o! for the "lini"al da#

All areas of the CI$ %U$& 'e "ompletel filled o!t# If "ertain areas of the CI$ is not appli"a'lethen write in (N)A’#

Student Name: _______Todd Shumay________________ Date of care: ______12/03/15________

Date of admission: __11/24/15__ !e: __14 yr o"d #t: __55_$%!& Se': __(___ Code Status: _)u"" Code___________ ""er!ies $and reaction to a""er!ies:_*o"air $+ma"i,uma-&_

ttendin!: _$.eds/)./Sur!ica"/.sych&_ ________________________________________________ t: ____1525____$cm& ________ #t: ___55__$%!& _________

dmittin! dia!nosis: _______nfection of ortacath "eadin! to sesis "so had se6ere nausea and6omitin! on admissionSur!ica" .rocedure: _______________________________________________________________

________________________________________________________________________________

istory of .resent ""ness $#hat -rou!ht atient to the hosita"7 #hat were the si!ns and symtomsthat -rou!ht atient to hosita"7&: _.atient admitted d/t infection of his ortacath which "ead tosesis e was -rou!ht into the .C8 where the sesis reso"6ed e was then -rou!ht down toinatient d/t fun!a" infection of his "ower "eft "o-e Confirmed of ha6in! ""er!ic 9ronchou"monary

ser!i""osis $9.& .atient was showin! oor .)Ts dirty!reen mucus secretions -i"atera"crac%"es -i"atera" -ronchiectasis with the "eft "o-e more ro-"ematic

.ertinent .ast (edica" istory: .atient has a history of oor"y mana!ed cystic fi-rosis .ortacath"acement on ri!ht uer chest and 8m-i"ica" ;tu-e

Current Diet $Tye and 10kg>20 kg 1500 mL + 20 mL/kg foreach kg>20kg

1500?20$35&@2200 m" er day*+#, ml)hr


2/19


De-elopmental:.ri/son 0 1hat stage is patient in a""ording to age2

A""ording to .ri/sons stage of ps"hoso"ial de-elopment he is in theIdentit -s role "onf!sion stage#

A""ording to o!r referen"es)reso!r"es3 what is e4pe"ted at this stage 5i#e#3 gross

motor de-elopment3 tal/ing how man words3 et"62 do"escents at this sta!e de6e"o a sense of ersona" identity and come to 6iewthemse"6es as uniIue indi6idua"s They are hi!h"y inf"uenced -y their eer !rou ;rossmotor de6e"oment is fu""y de6e"oed se'ua" maturation occurs and se"fe'"orationoccurs

After "aring for patient3 what did o! assess2 Did patient meet this stage2 Ifpatient did not meet this stage3 what stage does patient fit into2

assessed that my atient was a norma" ado"escent -oy hysica""y and co!niti6e"y ewas "ayin! 6ideo !ames a "ot throu!h the mornin! had comic -oo%s and the nurses

and him Jo%ed a-out !ir"s he "i%ed e showed interest in his schoo" e'ressed how heis fai"in! math and needs he" and -ein! unsure a-out what he wants to do when he!rows u e ta"%ed a-out his friends and their interest in 6ideo !ames as we"" wou"dsay that my atient fits in the identity 6s ro"e confusion throu!h his interest in his ho--iesand eer inf"uence and rea""y seein! himse"f as different not on"y -y his medica"dia!nosis -ut throu!h his interests

Piaget 7 1hat stage is patient in a""ording to age2A""ording to Piaget’s "ogniti-e de-elopment he is in the formal operations stage#

A""ording to o!r referen"es)reso!r"es3 what is e4pe"ted at this stage 5i#e#3 gross

motor de-elopment3 tal/ing how man words3 et"62Durin! this sta!e the ado"escent is a-"e to thin% throu!h more than two cate!ories of6aria-"es concurrent"y caa-"e of e6a"uatin! the Iua"ity of their own thin%in! and a-"e tomaintain attention for "on!er eriods of time They are hi!h"y ima!inati6e and idea"isticincreasin!"y caa-"e of usin! forma" "o!ic to ma%e decisions and thin% -eyond currentcircumstances and a-"e to understand how the actions of an indi6idua" inf"uence others

After "aring for patient3 what did o! assess2 Did patient meet this stage2 Ifpatient did not meet this stage3 what stage does patient fit into2

I assessed that "ogniti-el this "hild is appropriate for this stage# 8e tho!ghlogi"all and was a'le to tal/ a'o!t his "ondition from his medi"ation regimen3reasons for the medi"ations3 and !nderstanding of treatments# 8e was attentati-eand maintained "on-ersation for long periods of time# 8e also was tal/ing a'o!thow his plans to ta/e s!mmer s"hool so that he "an reall !nderstand math# Iwo!ld sa he is in the "orre"t stage of "ogniti-e tho!ght#


3/19


Patient ed!"ation: List all possi'le areas of patient ed!"ation o! "o!ld tea"h patient while inhospital and for planned dis"harge# 5i#e#3 medi"ations3 disease pro"ess3 safet3imm!ni9ations3 diet3 phsi"al restri"tions3 "ast "are3 home "are3 o!tpatient reso!r"es3 follow7

!p appointments et"6 51hat does patient need to /now in or to 'e dis"harge26

.n"o!rage parents to parti"ipate in plan of "are and reinfor"e I and O’s3 n!tritional inta/e3 andmedi"ation timeliness7 .arents and chi"d showed minima" interest in adherin! to the nurses/doctors"an of care .arents showed "ac% of arentin! in reinforcin! teachin!s and %now"ed!e of imortanceof maintainin!/monitorin! these areasGrief Co!nseling for the parents and possi'l the "hild7 Chi"ds ro!nosis is oor and arentscou"d ro-a-"y use !rief counse"in! a-out ossi-"e com"ications that may arise f/when the chi"dfinds out more a-out his condition he cou"d -enefit not on"y a-out his treatment and condition -utossi-"e stress and sycho"o!ica" he"

In"reasing N!trition7 ncreasin! ca"ories and nutrition is imortant so that the chi"d maintains -odywei!ht and aroriate nutrients durin! his treatmentAdhering to %edi"ation Regimen and 'eing aware and wat"hf!l for medi"ation side effe"ts7.atient is retty aware and %now"ed!ea-"e a-out ta%in! his medication 9ut "ac%s understandin! inthe imortance of ta%in! it in a time"y manner .atient waits hours to eat/doesnt eat so some of hismedications are either de"ayed or ro6ide no -enefit if he does not eat 9ein! aware of the sideeffects such as diarrhea from his anti-iotics/antifun!a"s is imortant teachin! in conJunction with his and +sProper positioning and maintaining airwa "learan"e7 ncoura!in! dee -reathin! andmaintainin! roducti6e cou!h can he" decrease mucus -ui"d u in his "un!s .erformin! re!u"archest hysica" theray with arents can a"so -e -eneficia"

Respirator therap7 Can he" encoura!e effecti6e airway c"earance and adeIuate "un! functiono'y!en saturation and erfusion/o'y!enationPhsi"al &herap ncreasin! acti6ity can -enefit in ; moti"ity resiratory effort cardio6ascu"ar andmuscu"os%e"eta" systemsInfe"tion Control7 a6in! the arents the atient and other staff freIuent"y 6isitin! the atienterform !ood hand hy!iene and roer infection contro" recautions can decrease chances fornosocomia" infections "eadin! to further immuno"o!ica" comromise&reatment .d!"ation7 ducatin! atient and arents on "an of treatment with medications (


4/19


LA; R.$UL&$: In"l!de admission la's3 and last < 5two6 das

La' &est NormalRange

Res!lts = Dates Rationale for A'normalLa' Res!lts

C;C 12/01 12/02

#9C55155

1KB i!h 2KE i!h .atient is not on"y reco6erin!from ha6in! sesis -ut isnow fi!htin! a!ainst a

difficu"t fun!a" infection in his"un!s .atients immunesystem is wor%in! e'tra hardto fi!ht the infections -yincreasin! the amount of#9Cs

K3EE

E14 E1K

(CC323

32 323


5/19


infection to he" rid anddi!est forei!n su-stances

os04

32 0E

9aso01

02 01

.L.C&ROL>&.$)R.NALPAN.L);A$IC %.&A;OLICPAN.L

12/1 12/2

Na? +?@7+@ 13B 135

L? ?#@7@ 4B 4K

C" +B


6/19


Tota" .rotein2KB

2 2

Tota" 9i"i 0112 02 02

Direct 9i"i

"-umin 3550 3 3K

AT K55 12 13

ST E4E 15 13

S;+T

"% .hos 45115 20B i!h 214 i!h .atient has C) C) cancontri-ute to -"oc%ed Ductsand (a"nutrition The-"oc%ed ducts may interferewith "i6er function causin! anincreases A.

;LOOD CUL&UR.Site:


7/19


P.R&IN.N& DIAGNO$&IC &.$&$ 5i#e# .KG3 C& $CAN3 ERA>$3 et"6: F!se 'a"/ of page for more

Date Diagnosti" &est Reason for test Res!lt)Impression: N!rsing Inter-entions5i#e#3 tea"hing3

preparation et"6

++) I12h

$55&@330m!/I12S

N/> diarrheaheadache Jointain wea%nesssore throathotoho-ia

dminister 1 hour -efore or aftermea"s

0E00100

mi%acinmi%in&0m! s"na"ation 9D

ntio-iotic mino!"ycoside

9actericida" Gtreat infection inthe "un!s

1530m!/%!/daydi6ided in I1224h

15$55&30$55&@E25150m!/2@4125E25m!/I12

S

Confusionderessionnum-nesshematuria rena"dama!eneuroto'icity

+-tain COS tests-efore -e!innin!roduct

0E00100


8/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______ tiri,ine $Pyrtec&m! ta-a" Dai"y

ntihistamine.iera,ine 1histamineanta!onist

""er!yurticaria" rhinitis

510m! dai"y .+

S

eadachefati!ue drymouth thic%enin!of -ronchia"secretions

Ta%e on emtystomach G foodro"on!sa-sortion -y1Khrs

0E00

uticasoneonase&

mc! sraysa" Dai"y

Corticosteroids stiasthmatic

Chronic asthma nasa"

symtoms

EE0mc! 9D

N+ too "ow

.haryn!itisdi,,iness ora"

candidiasis-ronchosasmsan!ioedema

Ta%e-ronchodi"ator

first Do not usefor acute asthmaattac% Taerdown if usin!"on! term

0E00

trity"ineame"or&m! caa" QS

ntideressantDi-en,ocyc"ohetene

Deression orchronic ainmana!ement

13m!/%!/day in 34 di6ided doses orat -edtime

1$55&3$55&@5515m!/4@13K54125m!/dose

S

Di,,inessdrowsinesshyotension

-ronchosasm

;i6e aftersha%in! inha"er

""ow at "east 1min in -etween-reaths

0E0012001002000

nsora,o"e

re6aciduta-&m! ta-a" 9D

ntiu"cer roton

um inhi-itor 9en,imida,o"e


9/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______ N+ too hi!h

cafun!inycamine&0m! nJ.9 I24h

ntifun!a"chinocandin

Direct dama!eto fun!a" wa""

152m!/%!/day

15$55&2$55&@E25110m!/day

S

eadacheanore'ia N/>con6u"sionsanemia

+-tain COS tests-efore -e!innin!roduct

ona-ino"

arino"&! caa" 9DC

Canni-inoids )or N/> a"so

treat "oss ofaetite andwei!ht "oss

255m!/dose

S

#ea%ness

stomach ainmemory "osssei,urestachycardia

;i6e -efore "unch

and dinnerSwa""ow casu"eswho"e do notcrush s"it chew

1200

1E00

enemrima'in&0m! nJ.9 Ih

ntiinfecti6eCar-aenem

9actericida" 0100m!/%!/day indi6ided doses ma'4!/day

0$55&100$55&@33005500m!/day

K50'4@3000N+ too "ow

Diarrhea N/>sei,uresheatitis rena"to'icity h"e-itis

;i6e dose o6er2030 min do notmi' with otheranti-iotics

0K0013001B00

nnosidesenna&m! ta-a" 9D

Aa'ati6estimu"antanthraIuinone

Decreaseconstiation

Em! not toe'ceed 2 ta-s$1K2m!/day&

S

N/> anore'iaa-domina"crams diarrheaf"atu"ence tetany

dminister onemty stomach!i6e with fu""!"ass of water

0E00100

sacona,o"e0m! ta-a" IEh

,o"e antifun!a" 8sed tore6ent/treatfun!a" infections

300m! .+ 9D

S

Swe""in! chi""sdiarrhea-"eedin! "oss ofaetite nausea

Ta%en with a fu""mea" or "iIuidnutritiona"su"ement

osoma"mhotericin 9m-isome&0m! nJ.9 I24h

ntifun!a" Treats infectionscaused -yfun!us

10m!/%!/day

10$55&@550m!/day

N+ too hi!h

Chi""s fe6erirre!u"arheart-eatmusc"e cramswea%nesstiredness

)"ush -efore andafter with D5#

1100

"yethy"eneyco" $(ira"a'&!m owder %tu-e I24h

+smotic "a'ati6e )or constiation +ne ac%et of 1K!rams in any 4Eo'of water once aday

S

Diarrheanausea stomachcramsf"atu"ence

(i' with Eo, off"uid

1100

PRN %.DICA&ION$ Referen"e 1t:5/g6edicationade Name

neric Name


10/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______ ea caa" .


11/19


m-a"anced Nutrition re"ated tooor nutritiona" inta%e and

need for increased ca"ories tomeet meta-o"ic demands

ncrease ca"ories in atients diet;i6e referred foods+ffer more freIuent feedin!sand snac%s(onitor and +s(onitor for s/s of im-a"ancenutrition or ma"a-sortion

(onitor wei!hts ener!y "e6e"and "e6e" of consciousnessTa%e medication with mea"s toenhance a-sortion anddi!estion of foodncoura!e arents to reinforceteachin!s

This was a 6a"id riority toidentify fee" his nutrition is a!ood third riority Theinter6entions did address hisneed -ut atient need consistentreinforcement in the imortanceof nutrition The inter6entions

were aroriate to the atientsneeds #hat wou"d do differentto ma%e sure that the atients and +s are strict and adheredto .arenta" in6o"6ement wasoor so rea""y reinforcin! theimortance is needed

nfection re"ated to resiratoryfun!a" infection

dministerantifun!a"s/anti-iotics in a time"ymanner

(onitor for s/s of medicationnterret "a- 6a"ues/ dia!nosticrocedures for effecti6eness.ractice enhanced recautionsncoura!e !ood hy!iene foratient atients fami"y and staff Aimit 6isitors and ro6idec"ustered care(onitor for s/s of increasedinfection(onitor 6ita" si!ns such as

tem


12/19


&I%. &A;L.

BHBBHourly Rounding

I LeftAC

Inepen!m7 +@B ml)hr

BBBHourly Rounding

I LeftAC $)Assessment

& *#?8R +?+RR ?+;P ++@)HBO< $ats **M RA

B*BBHourly Rounding

I LeftAC

an"om"in7 ;ilateral .4pirator Cra"/les in lower lo'es3 Left Lo'e so!ndsmore diminished then right3 Green m!"!s3 &a"hpni" at ?+'reaths per min!te#

GI)GU ;owel so!nds present in all !adrants3 no pain on palpation3Last ;%)oid at B@?B#

$KIN)%U$CULO$K.L.&AL $/in "lamm and warm to to!"h3 $/in t!rgor ? se"onds3 Goo"oordination and mo-ement3 ;od smmetri"al3 No signs onimpaired s/in integrit#


13/19


R.%.%;.R &O DO CAR.PLAN AND 1..KL> R.L.C&ION

!"# $20 %A&'"AL()*L, )L)AL -''.L #'L "'L')&#

&hi3 week in c4inica4 had the opportunity to e on the inpatient oor6 &he patient

that wa3 a4e to focu3 on wa3 a 17(year(o4d oy with a re3piratory funga4 infection and

hi3tory of cy3tic 8ro3i36

%y patient wa3 admitted to the 9)! on the 27th for 3ep3i3 due to hi3 infected port(

a(cath which wa3 remo:ed6 After that re3o4:ed he came down to inpatient due to hi3

funga4 infection6 After getting report my nur3e and went in to the patient3 room6 #ince it

wa3 3ti44 ear4y and he wa3 3ti44 34eeping; we arou3ed him; and did a


14/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______ A3 far a3 thi3 patient3 condition goe3; he i3 infected with a :ery powerfu4 fungu3

ca44ed a3pergi44o36 *i3 condition i3 ca44ed a44ergic ronchopu4monary a3pergi44o3i3 which

tend3 to occur in chi4dren with cy3tic 8ro3i36 After many dierent treatment3 of

antifunga4 medication3; nothing ha3 3eemed to e working6 %y nur3e de3cried the

pathophy3io4ogy of thi3 condition a3 it eing necrotic to 4ung ti33ue that can cau3e him to

4eed out and die6 &he progno3i3 of morta4ity of thi3 condition i3 aout $0(5C6

!nfortunate4y due to the 3e:erity of hi3 condition and infection; the doctor3 are ha:ing a

diDcu4t time in treating it6 had the opportunity to 3it in on a doctor3 di3cu33ion of thi3

chi4d a3 they 3poke aout and di3cu33ed po33i4e treatment option36 A4though fee4 4ike

on4y under3tood ha4f of what they were 3aying; it wa3 :ery intere3ting eing apart of

that6 &hey were con3u4ting top funga4 e?pert3 and pu4mono4ogi3t3 around the wor4d; and

pretty much the conc4u3ion of treatment i3 tria4 and error6 &hey fear that thi3 infection

wi44 3pread to hi3 rain and further comp4ication36 #o they ha:e ordered %"; )& 3can;

)he3t E(ray3; and a 4ung iop3y Fwhich i3 high ri3k for rupturing and 4eeding outG6 wa3

amaHed on how hard each doctor i3 working to 3a:e thi3 chi4d@3 4ife6 t wa3 a :ery inten3e

fee4ing6

or thi3 patient3 fami4y; there wa3 an intere3ting re4ation3hip etween the chi4d

and hi3 parent36 &hi3 chi4d ha3 a hi3tory of poor4y managed cy3tic 8ro3i3 part4y/mo3t4y

due to 4ack of parenta4 in:o4:ement in managing hi3 condition6 n report it wa3 3aid that

thi3 chi4d ha3 een pretty much taking care of him3e4f 3ince he wa3 10 year3 o4d from

feeding him3e4f to taking hi3 own medication6 *i3 parent3 do not 3eem to e taking hi3

current condition or pa3t medica4 hi3tory :ery 3eriou3 and 3how 4ack of in:o4:ement and

4ack of intere3t6 am not 3ure if they are Iu3t in denia4 or what; ut their eha:ior and

action3 are pointed at the chi4d@3 fau4t for not managing hi3 condition etter; when in

rea4ity he i3 Iu3t a kid6 &he fami4y in:o4:e3 a mom and dad; the patient; and two younger


15/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______ rother36 inancia44y; thi3 fami4y i3 doing poor4y6 %y nur3e wa3 e?p4aining that the parent3

were going to 3pend o:er two thou3and do44ar3 on comic ook co44ection rather than

3pending their money on other nece33itie3 that thi3 fami4y need3; 4ike 3hoe3 for the

midd4e chi4d who ha3 no 3hoe36 &hey a43o go to the food ank e:ery day 3o that their

fami4y can eat6 t3 amaHing to 3ee 3uch poor fami4y 3tructure and the 4ack of in:o4:ement

and impact that thi3 patient i3 going through due to hi3 Jneg4ectfu4K parent36

A rea4 pro4em for the nur3e3 ha3 een diDcu4ty in the accurate and 3 and

nutritiona4 intake6 ':en though there ha3 een con3tant reinforcement 3tre33ing the

importance of and @3 and eating to the patient and fami4y; it ha3 een poor4y recorded

and performed6 #ince the parent3 aren@t taking it 3eriou3; the chi4d 3uer3 and goe3 y

e?amp4e of the parent36 can rea44y 3ee how diDcu4t it i3 for a chi4d to reco:er and

eha:e if the parent3 are not acting profe33iona4 or 3eriou36

,ue to the poor progno3i3 of thi3 chi4d@3 condition; doctor3 had a fami4y meeting

with the parent3 to di3cu33 the poor outcome3 of thi3 chi4d@3 3tatu36 An intere3ting a3pect

of thi3 i3 that the parent3 ha:e known that their chi4d i3 high4y 4ike4y to pa33 any minute

from thi3 funga4 infection ut ha:e decided not to inform their 3on of hi3 condition Fa3 far

a3 my 3hift wentG6 #o thi3 chi4d doe3 not know that he i3 e33entia44y dying or how 3eriou3

hi3 condition i36 *e i3 unaware of how hard nur3e3; doctor3; and re3piratory i3 working to

3a:e hi3 4ife6 'thica44y fee4 that the chi4d 3hou4d know of hi3 condition; ut 4ega44y the

parent3 are not 4etting him know6 n top of that; due to the 4ack of 3eriou3ne33 from the

parent3; it3 e:en more fru3trating knowing that they know hi3 progno3i3 yet they ha:e no

under3tanding that they are part4y/mo3t4y to 4ame of not managing their chi4d@3

condition6 &hey are not participating in hi3 p4an of care and 3how no intere3t in preparing

the patient for po33i4e outcome3 FdeathG6 *eartreaking to 3ee6


16/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______ fe4t 4ike wa3 in3ide a medica4 &= 3how6 t had a44 the a3pect3 of addre33ing

pro4ematic condition3; ethica4 di4emma3; 3u3pen3efu4 twi3t3; and ending with a to e

continued

&he 8r3t #L that wi3h to addre33 i3 app4ying the AA code of 'thic3 to care of

fami4ie3 inc4uding c4ient3 right3; di4emma3 etween indi:idua4 right3 and the common

good; identi8cation of choice3 and po33i4e con3e


17/19

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______ 3uering from the poor deci3ion3 of the parent3 i3 the chi4dren; e3pecia44y my patient

with )6

:era44; my day wa3 a 4ot to take in6 rom under3tanding hi3 condition and po33i4e

treatment3; to the fami4y dynamic3; to a44 the ethica4 3ituation3 in(etween; wa3 inten3e

a3 much a3 it wa3 intere3ting6 t rea44y opened my eye3 to how important the fami4y i3 in

the progre33 and condition of the patient6 'thica44y; the di4emma of the chi4d not knowing

hi3 condition wa3 a43o eye opening6 ha:e ne:er 3een a 3ituation where doctor3 don@t

know what to do6 t3 3cary yet


18/19


ation a 'rodu*ti+e *ou.h andatory rate within normal ran.es

. hour shift%

Termnt will ha+e no si.ns oroms of res'iratory distress andaintain a *lear effe*ti+e airway. and after hos'itali0ation for hs% atient and 'arents willstand the need for an effe*ti+ey *learan*e and 'erform dailyatory *he*-s%

saturation and blood .as +alues e+eryhour

2%osition 'atient from abo+e 345de.rees%

3%erform *hest 'hysiothera'y and'ostural draina.e e+ery 4 hours anden*oura.e dee' breathin. and*ou.hin. te*hniues and en*oura.e'arental 'arti*i'ation%

4%&dminister antifun.als antibioti*s andbron*hodilators%

5%Tea*h 'atient and family to adhere tomedi*ation re.imen%

%&''ro'riate e,er*ise en*oura.e restand *luster *are and limit +isitors%

6% 7a+e su*tion eui'ment and o,y.ena+ailable

% Note *hara*teristi*s of s'utum

*an indi*ate res'iratory distress or failure%Normal res'iratory rate for this 'atientshould be between 1222% Se*retions inthe airway will *ause the 88 to in*rease%9onitorin. e+ery hour is ne*essary toassess res'iratory status (ulani*- and9yers '. 12)

2% ;ee'in. the 'atient in an u'ri.ht 'ositionallows for ma,imal air e,*han.e and lun.e,'ansion%


19/19


"% ?n*rease fluid inta-eand odor of s'utum *an indi*ate *urrent

worsenin. or re*o+ery from infe*tion%(ulani*- and 9yers '. 12)

"% ?n*reasin. fluid inta-e *an hel' thinse*retions and ensure that the *lient ishydrated% (ulani*- and 9yers '. 12)

im'ro"% atie

and hNS *

C$NT?N

u4anick %6; O %yer3; P6 F2017G6 ur3ing care p4an3 diagno3e3; inter:ention3; andoutcome36 FQth ed6G6 9hi4ade4phia; 9A6 '43e:ier6

cf patient tshumway

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