Competency Appraisal 1 Activity 2

SAINT LOUIS UNIVERSITY SCHOOL OF NURSING

COMPETECY APPRAISAL
ACTIVITY 2
Submitted to: Mrs. Cheryl Bandaay Sbmitted by:

BSN IV Block J Group 2

Yap, Carlo Enrico Yogyog, Johnlee Alma-in, Alyssa Cayabyab, Thea Clarice Condeno, Renalyn Roseclaire Gamboa, Ceillo Marie Guerrero, Nema Jovinni Lad-ey, Jessa Mae Lucero, Catherine Palayen, Goldamaire Ramos, Kristen Saballa, Lyra Valentin, Princes

CN110 Competency Appraisal 1 M 130 400 S502

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June 20, 2011

Competency Appraisal 1 Activity 2

WHY ARE NEWBORN BABIES OBLIGATE NOSE BREATHERS?

Newborns need to breathe

primarily through their nose arises from the physical structure of their mouth. In a newborn s mouth, oral breathing is potentially difficult because the soft palate --a muscular fold that extends from the back of the roof of the mouth--is so close to the epiglottis--a flap of cartilage that covers and protects the windpipe during the act of swallowing.

Figure 1 Comparison of the adult and infant upper airway

According to Annie Bagnall, contributing author for "Feeding and Nutrition in the Preterm Infant," physical growth occurring at approximately 6 months of age moves the soft palate and epiglottis further apart, thus leading to an opening up of the oral area and a marked increase in your infant's ability to breathe orally. In addition, babies have to breathe through their noses because nature designed them to use their mouths to suckle firmly on the only intuitive interface. The only time babies breathe through their mouths is when they cry.

WHY CHILDREN COMMONLY DEVELOP CROUPY COUGH COMPARED TO ADULTS?

The symptoms of croup are caused by inflammation, swelling and the buildup of mucus in
the larynx, trachea (windpipe) and bronchial tubes. Since younger infants and children have smaller airways, they are the ones most affected by croup. Children are more likely to develop croup because of their tiny airways. Their breathing passages cannot accommodate the inflammation caused by croup. BSN IV J2 In contrast with the adults, they don t get croup often because their trachea and larynx (the breathing passages) are larger.
Figure 2 Narrow infant airways causes croup.

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WHY ARE CHILDREN PRONE TO DEVELOP RESIRATORY TRACT ILLNESS COMPARED TO ADULTS?

Children are more likely to develop infections in their lungs, because their lungs aren t as
strong in fighting off theses infections. And, most often, viral respiratory tract infections spread when children's hands come into contact with nasal secretions from an infected person. These secretions contain viruses. When the children touch their mouth, nose, or eyes, the viruses gain entry and produce a new infection. Less often, infections spread when children breathe air containing droplets that were coughed or sneezed out by an infected person. For various reasons, nasal or respiratory secretions from children with viral respiratory tract infections contain more viruses than those from infected adults. This increased output of viruses, along with typically lesser attention to hygiene, makes children more likely to spread their infection to others.

Figure 3 Thumb sucking increases the respiratory track illnesses in children.

The possibility of transmission is further enhanced when many children are gathered together, such as in child care centers and schools.

TRACE THE PATHOPHYSIOLOGIC OCCURANCES THAT LEAD TO THE DEVELOPMENT OF BRONCHIECTATASIS.

Predisposing Factors: Recurrent Respiratory Infections Measles Influenza Tuberculosis Immuno-deficiency disorders Toxic gas exposure CF Young syndrome Ciliary dyskinesia Marfan Syndrome Mounier-Kuhn syndrome Williams-Campbell syndrome Immunoglobulin A and G Deficiency Modifiable Factors: Lifestyle Environment Diet Non-modifiable Factors: Idiopathic inflammatory disorders

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Chronic Infection

Inflammatory process associated with pulmonary infections damage to bronchial wall

Recruitment of neurophils, T lymphocytes, and monocytederived cytokines

Release of inflammatory mediators, elastases, and collagenases

Loss of pulmonary supporting structures

Thick sputum

Inflammation and destruction of elastic and muscular components of bronchial walls

Outward elastic recoil forces surrounding lung parenchyma to exert traction

Impairement of mucocillary clearance

Obstruction in the bronchi

Shortness of breath, productive cough, chest pain, loss of appetite

Expansion of airway diameter

Lung abscess

Bronchial arterial proliferation

Exudates drains freely through the bonchus

Hemoptysis
Retention of secretions

Inflammatory scarring or fibrosis replaces functioning lung tissue

Cause alveoli distal to the obstruction to collapse (atelectasis)

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Respiratory insufficiency with reduced vital capacity, decreased ventilation, increased, ratio of residual volume to total lung capacity

Hyperventilation

Ventilation perfusion imbalance, hypoxemia

Clubbing of fingers and nails

BRONCHIECTASIS

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CATEGORIZE THE FOLLOWING ACCORDING TO ANATOMIC DEFECT AND DESCRIBE THE SHUNTING OF BLOOD:
A. ATRIOSEPTAL DEFECT B. VENTRICULAR SEPTAL DEFECT C. TETRALOGY OF FALLOT D. COARCTATION OF THE AORTA E. TRANSPOSITION OF GREAT ARTERIES F. PULMONARY STENOSIS G. PATENT DUCTUS ARTERIOSUS

SEPTAL DEFECTS Atrial Septal Defect

SPECIFIC ANATOMICAL DEFECT

An abnormal communication between the two atria (an acyanotic defect): An ASD is a hole in the part of the septum that separates the atria the upper chambers of the heart. This heart defect allows oxygen-rich blood from the left atrium to flow into the right atrium instead of flowing to the left ventricle as it should. An opening is present in the septum between the two ventricles: A VSD is a hole in the part of the septum that separates the ventricles the lower chambers of the heart. The hole allows oxygen-rich blood to flow from the left ventricle into the right ventricle instead of flowing into the aorta and out to the body as it should.

SHUNTING OF BLOOD
Blood flow is from left to right (oxygenated to deoxygenated) because of the stronger contraction of the left side of the heart. This causes an increase in the volume in the right side of the heart and generally results in ventricular hypertrophy and increased pulmonary artery blood flow

SEPTAL DEFECTS
COMPLEX DEFECT

Ventricular Septal Defect

Because pressure in the left ventricle is greater than that in the right ventricle, blood shunts from left to right across the septum (an acyanotic disorder). This impairs the effort of the heart because blood that should go into the aorta and out of the body is shunted back into the pulmonary circulation, resulting in right ventricular hypertrophy and increase pressure in the pulmonary artery.

COMPLEX HEART DEFECT Tetralogy of Fallot

SPECIFIC ANATOMICAL DEFECT

Four anomalies are present: -pulmonary stenosis -ventricular septal defect (usually large) -dextroposition of aorta (overriding) -hypertrophy of the right ventricle

SHUNTING OF BLOOD
Because of the pulmonary stenosis, pressure builds up in the right side of the heart. Blood then shunts from this area of increased pressure into the left ventricle and the overriding aorta. The extra effort involved to force blood through the stenosed pulmonary artery causes the 4th deformity, hypertrophy of the right ventricle

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VESSEL DEFECTS Transposition of Great Vessels

SPECIFIC ANATOMICAL DEFECT

The aorta arises in the right ventricle instead of the left, and the pulmonary artery arises from the left ventricle instead of the right.

SHUNTING OF BLOOD
Blood enters the heart from the vena cava to the right atrium, then flows to the right ventricle, and goes out into the aorta to the body completely deoxygenated; it returns again by the vena cava. A secondary source of the blood enters the heart from the pulmonary veins, goes to the left atrium, left ventricle, and out the pulmonary artery to the lungs to be oxygenated, and returns to the left atrium, a second close circulatory system. If it fails to close at birth blood will shunt from the aorta (oxygenated blood) to the pulmonary artery (deoxygenated blood) because of the increase pressure in the aorta. The shunted blood returns to the left atrium of the heart, passes to the left ventricle, out to the aorta, and shunts back to the pulmonary artery. This causes increased pressure in the pulmonary circulation from the extra shunted blood; this leads to right ventricle hypertrophy and ineffective heart action.

VESSEL DEFECTS OBSTRUCTIVE DEFECTS

Patent Ductus Arteriosus

Ductus arteriosus is an accessory fetal structure that connects the pulmonary artery to the aorta.

OBSTRUCTIVE DEFECTS Pulmonary Stenosis Coarctation of the Aorta

SPECIFIC ANATOMICAL DEFECT

Narrowing of the pulmonary valve or the pulmonary artery just distal to the valve. Narrowing of the lumen of the aorta due to a constricting band. Two location in which this commonly occurs: 1. Preductal- constriction occurs between the subclavian artery and the ductus arteriosus 2. Post ductal- constriction is distal to the ductus arteriosus

SHUNTING OF BLOOD
Inability of the right ventricle to evacuate blood by way of the pulmonary artery because of the obstruction leads to right ventricular hypertrophy. Because it is difficult for blood to pass through the narrowed lumen of aorta, blood pressure increases proximal to the coarctation and decreases distal to it. This results in increased blood pressure in the heart and upper portions of the body as pressure in the subclavian artery increases.

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DIFFERENTIATE SIGNS AND SYMPTOMS OF LEFT AND RIGHT SIDED HEART FAILURE.

Left-sided heart failure or left ventricular failure (LVF) is a reduction in the output from the
left ventricle. The pressure in the left atrium increases as the oxygen-rich blood from the lungs is backed up since the left ventricle is not pushing out this blood fast enough or efficiently.

Right-sided heart failure or right ventricular failure (RVF) is a reduction in the blood output
from the right ventricle. The pressure in the right atrium may be decreased, normal or increased depending on the return of blood from the rest of the body.

Signs/Symptoms
Pitting Edema (Legs, Hands) Fluid Retention

Left-Sided Heart Failure

Mild to moderate. Pulmonary edema (fluid in lungs) and pleural effusion (fluid around lungs). Heart. Mild to moderate raised jugular venous pressure (JVP). Prominent dyspnea. Paroxysmal nocturnal dyspnea (PND). Present but not as prominent.

Right-Sided Heart Failure

Moderate to severe Abdomen (ascites).

Organ Enlargement Neck Veins Shortness of Breath Gastrointestinal

Liver. Mild jaundice may be present. Severe jugular venous pressure (JVP). Neck veins visibly distended. Dyspnea present but not as prominent. Loss of appetite, bloating, constipation. Symptoms are significantly more prominent than LVF

OTHERS:

Left-sided Heart Failure

y

Ineffective left ventricular contractile function o increased workload and end-diastolic volume enlarge the left ventricle Pumping ability of the left ventricle fails, cardiac output falls o right ventricle becomes stressed because it's pumping against greater pulmonary vascular resistance and left ventricle pressure Blood backs up into left atrium and then into lungs o diminished function allows blood to pool in the ventricle and atrium and back up into the pulmonary veins and capillaries o rising capillary pressure pushes sodium and water into interstitial spaces o fluid in the extremities moves into the systemic circulation

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Signs and symptoms o dyspnea o orthopnea o paroxysmal nocturnal dyspnea o reduced sympathetic stimulation while sleeping o pulmonary congestion o tachycardia o S3 o S4 o Cool, pale skin o restlessness

Right-sided Heart Failure

y

Ineffective right ventricular contractile function o stressed right ventricle enlarges with the formation of stretched tissue Blood backs up into right atrium and peripheral circulation o blood pools in the right ventricle and right atrium o backed-up blood also distends the visceral veins Patient gains weight and develops peripheral edema o rising capillary pressure forces excess fluid from the capillaries into the interstitial space Signs and symptoms o jugular vein distention o positive hepatojugular reflux o hepatomegaly

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DESCRIBE THE TIMELINE FOR DOING CORRECTIVE SURGERY FOR CLEFT LIP AND CLEFT PALATE AND INCLUDE RATIONALE.
0 months 3 months 6 months 9 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years

AGE CONDITION
Palatal Obturator

Repair cleft lip Repair soft palate Repair hard palate Tympanostomy tube Speech therapy/Pharyngopla sty Bone grafting jaw Orthodontics
Further cosmetic corrections

PALATAL OBTURATOR
a prosthesis that totally occludes an opening such as an orinasal fistula (in the roof of the mouth)

Rationale:
Palatal obturators are typically short-term prosthetics used to close defects of the hard/soft palate that may affect speech production or cause nasal regurgitation during feeding. Following surgery, there may remain a residual orinasal opening on the palate, alveolar ridge, or labial vestibule. A palatal obturator may be used to compensate for hypernasality and to aid in speech therapy targeting correction of compensatory articulation caused by the cleft palate. In simpler terms, a palatal obturator covers any fistulas (or "holes") in the roof of the mouth that lead to the nasal cavity, providing the wearer with a plastic/acrylic, removable roof of the mouth, which aids in speech, eating, and proper air flow.

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REPAIR OF CLEFT LIP

Within the first 2 3 months after birth, surgery is performed to close the cleft lip. Rationale: While surgery to repair a cleft lip can be performed soon after birth, often the preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10g hemoglobin).

REPAIR OF SOFT PALATE/HARD PALATE

Often a cleft palate is temporarily closed, the cleft isn't closed, but it is covered by a palatal obturator (a prosthetic device made to fit the roof of the mouth covering the gap). Cleft palate can also be corrected by surgery, usually performed between 6 and 12 months. Approximately 20-25% only requires one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the Latham appliance. The Latham is surgically inserted by use of pins during the child's 4th or 5th month. After it is in place, the doctor, or parents, turns a screw daily to bring the cleft together to assist with future lip and/or palate repair. If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the patient s own chin, rib or hip.

TYMPANOSTOMY TUBE
a small tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time. Rationale: The tube often allows for children to have improved hearing and provides other significant benefits.

SPEECH THERAPY/PHARYNGOPLASTY
Babies who suffer from cleft palate may have a number of speech problems. Some speech problems develop directly as a result of anatomical differences due to the birth defect. An example of an anatomical difference that could cause trouble is velopharyngeal inadequacy, which is the inability of the soft palate to shut the opening from the throat to the nasal cavity. Velopharyngeal inadequacy makes it difficult for children to make many speech sounds as the soft palate is integral to this function. These types of errors are somewhat common and can be corrected after palate repair. Pharyngoplasty is a kind of plastic surgery for the pharynx (soft tissue at the back of the mouth) when the tissue at the back of the mouth is not able to close properly. It is typically used to correct speech problems in children with cleft palate.

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BONE GRAFTING JAW

Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly.

ORTHODONTICS
Surgical repair of the lip and palate invariably leads to a series of secondary growth disturbances. These early surgeries tend to result in poor skeletal and dental growth in the transverse and antero-posterior planes, especially in the maxilla.

MAKE A 24 HOUR MEAL PLAN FOR A 10 MONTH OLD CHILD WITH CELIAC DISEASE AND CONSIDER SCHEDULE OF FEEDING. Meal Breakfast Time 6:00 AM Contents > 6oz apple juice > Buckwheat porridge with dried fruit and 1% milk >Gluten-free bread with margarine and jelly, honey or peanut butter >Yogurt >Gluten-free rice crackers with cheese and tomato >2 oz roasted chicken breast/any lean meat >2 slices gluten free bread >1 cup mixed salad >1/2 cup carrot sticks >1/2 cup bell pepper slices >1 medium apple, or 1/2 cup yogurt (check ingredients) ->Water, fruit juice, 1% milk >Frozen fruit with gluten-free custard or ice cream > Gluten-free muesli with fresh or canned fruit and milk >3 oz broiled pork chop >1 cup basmatic rice/rice noodles >1/2 cup green beans/stir-fry vegetable mix >Fruit juice, or water

AM Snack Lunch

8:30 AM 11:30 AM

PM Snack Dinner

3:00 PM 6:30 PM

Guidelines:
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Do not eat any foods that contain gluten. These include bagels, bread, crackers, malted
breakfast cereals, pasta, and pizza.

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 Look for wheat or wheat products added to foods such as ice cream, salad dressing, candy, canned and frozen soups and vegetables, and other processed foods.  When you eat out, look for restaurants that serve gluten-free food.  You might ask if the chef is familiar with cooking without any gluten.  Also look for grocery stores that sell gluten-free pizza and other foods

On a gluten-free eating plan, you can still have:

y

y y y

Eggs and milk products such as cheese. Some cheese and cheese spreads may contain gluten, so check the labels for additives. You may need to avoid milk and milk products at the beginning of treatment. Flours and starches made from rice, corn, buckwheat, potatoes, soybeans, or tapioca. Fresh, frozen, or canned unprocessed meats. Examples of processed meats are hot dogs, salami, and deli meat. Read labels for additives that may contain gluten. Fresh, frozen, dried, or canned fruits and vegetables, if they do not have thickeners or other additives that contain gluten.

IN PARADIGM FORM, COMPARE AND CONTRAST PHYSIOLOGIC EVENTS THAT LEAD TO DEVELOPMENT OF NEPHROTIC SYNDROME AND ACUTE GLUMERULONEPHRITIS.
LEGEND:
S/Sx for AGN Common for S/Sx

S/Sx for NS

ACUTE GLUMERULONEPHRITIS

NEPHROTIC SYNDROME

Predisposing factor: Children 2 years of age

Modifiable Risk factor: Exposure to certain meds, or foreign serum

Precipitating factors: Previous infection caused by Group A -Hemolytic Strep, Impetigo, Acute Viral Infections

Precipitating Factors: Chronic Glumerulonephritis, Diabetes mellitus with intercapillary glumerulosclerosis, Amyloidosis of the kidney, Systemic lupus erythematous, Multiple myeloma, Renal vein thrombosis

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Previous infection caused formation of antigen-antibody complex in the blood stream Deposition of immune complexes in the glumerulus

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WBC infiltrates the glumerulus Initiation of inflammatory process Damaged glumerular capillary membrane

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Thickening of the glumerular filtration membrane Decreased GFR Glumerular Injury Increased permeability of glumerular membrane

Oliguria UO < or = 30ml Circulatory overload

EARLY ONSET

Dyspnea, Jugular Vein Distention, Cardiomegaly, Pulmonary Edema

Cola-colored urine because of RBCs, protein plugs, and casts

Proteinuria

Loss of plasma protein

Hypoalbuminemia

Hematuria

Stimulation of synthesis of lipoprotein

Decreased oncotic pressure

Hyperlipidemia

Fluid shifting from vascular spaces to extracellular space

LATE ONSET

Activation of ReninAngiotensin System

Sodium Retention

Generalized Edema

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DESCRIBE THE APPROPRIATE COMMUNICATION TECHNIQUE TO BE USED WHEN CARING FOR A CHILD WITH:

A. SPEECH AND LANGUAGE DISORDER

y

Language intervention activities. In these exercises an SLP will interact with a child by playing and talking. The therapist may use pictures, books, objects, or ongoing events to stimulate language development. The therapist may also model correct pronunciation and use repetition exercises to build speech and language skills. Articulation therapy. Articulation, or sound production, exercises involve having the therapist model correct sounds and syllables for a child, often during play activities. The level of play is ageappropriate and related to the child's specific needs. The SLP will physically show the child how to make certain sounds, such as the "r" sound, and may demonstrate how to move the tongue to produce specific sounds. Oral motor/feeding therapy. The SLP will use a variety of oral exercises, including facial massage and various tongue, lip, and jaw exercises, to strengthen the muscles of the mouth. The SLP may also work with different food textures and temperatures to increase a child's oral awareness during eating and swallowing.

Communication Techniques:
y y y y y Learn the specifics of the child s speech or language impairment. The more you know, the more you can help and make communication or intervention fruitful.] Before starting the interaction minimize distractions or noise from the environment Look at the child when talking with him. Be patient. The language-impaired child, like every child, has a whole lifetime to learn and grow. Give the child chores or activities. Chores build confidence and ability. It keeps the child s age, attention span, and abilities in mind. Break down activities interventions into smaller steps or shorter time. Explain what to do, step by step, until the job is done. Demonstrate. Provide help when it s needed. Praise a job (or part of a job) well done. Listen to the child. Don t rush to fill gaps or make corrections. Don t force the child to speak. Be aware of the other ways in which communication takes place between people. Avoid or don t use inappropriate pitch or harsh voice Speak slowly and clearly. If the child has difficulty understanding, the use of short and simple sentences is beneficial. Pairing gestures with speech to help comprehension also helps.

y y y y y y

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Allowing the child ample time to respond and the formulation of questions that can be answered easily with a yes or no or other single word.

B. VISUAL IMPAIREMENT
y y y y y y y y y y y y y y y y Always announce your presence when entering the child s room and identify yourself with your name. Explain the sounds in the environment. Stay in the child s field of vision if the patient has a partial vision loss. Tell the child if you are leaving. Let him her know if others will remain in the room or if he she will be alone. Speak in a warm and pleasant tone of voice. Speak louder only when necessary. Use whatever vision remains. Allow the child to take your arm for guidance. When you speak, let the child know whom you are addressing. Ask how you may help: increasing the light, reading the menu, describing where things are, or in some other way. Always explain w hat you are about to do before touching the patient Call out the child s name before touching. Touching lets a person know that you are listening. Explain what you are doing as you are doing it, for example, looking for something or putting the wheelchair away. Describe walks in routine places. Use sound and smell clues. Encourage familiarity and independence whenever possible. Leave things where they are unless the person asks you to move something. Indicate when the conversation or interaction has ended and when you are leaving.

C. HEARING IMPAIREMENT Communication Techniques:

Reduce Noise in the Environment We use hearing to communicate and to hear environmental sounds. Even a mild hearing loss may interfere with clear communication. If a child can't hear speech clearly and consistently, then she will have more difficulty participating fully in activities with other people. y For a child with a mild hearing loss, you will want to make sure that background noise levels and loud music do not compete with conversation. Carpets, area rugs, and soft wall coverings help make a child care environment less noisy. Sound-absorbent material, such as cork board or carpet tiles on the walls, will help minimize noise in a room.

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Face the Child when you Speak A child with a hearing loss needs to see as well as hear what you say to him. You do not need to exaggerate lip movements but you must speak clearly. y y y Do not position yourself so he faces bright light and make sure visual barriers are minimized so that "line of sight" communication is possible. Furniture and bookcases should be low enough for children to see over them. When you show a child with a hearing impairment how to do something, use more demonstrations and gestures than you might with other children, but don't overdo it. Use Non-Verbal Cues to Communicate One way to get the attention of a child with a hearing impairment is to tap or thump on the table (if it's not too distracting for other children). She will respond to the vibration. You also can touch her on the shoulder or arm to get her attention if she is busy playing. Other visual cues include waving your arms, stamping your foot, or flashing the lights (flip the switch up and down a few times). y y Children in your setting can "role play" interactions so they learn how to communicate with each other. Explain to other children that if she does not respond to a verbal cue, it doesn't mean she's ignoring them. Be a Good Role Model Other children see how you behave and will copy you. If you develop effective communication strategies, other children will, too. If you ignore the hearing-impaired child, other children also may do the same thing. y Watch for signs of isolation, such as the child with a hearing impairment playing alone rather than with a group, or other children deliberately turning their backs on that child. If you see problems, handle it the same way you would any social or interpersonal difficulty.

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REFERENCES:
http: en.wikipedia.org wiki Cleft_lip_and_palate http: www.minfirm.com nj-pa-birth-injury-attorneys-topamax-cleft-lip-speech-hearing-problems Maternal and child health nursing care of the childbearing and the childrearing family 6th volume 2 edition pages 1207-1213 by Adele Pillitteri http: www.nhlbi.nih.gov health dci Diseases chd chd_types.html Brunner and Suddarth's Textbook of Medical-Surgical Nursing 10th edition http: emedicine.medscape.com article 1004692-overview#a0104 http: www.merckmanuals.com home sec04 ch047 ch047a.html http: www.nhlbi.nih.gov health dci Diseases brn brn_diagnosis.html http: emedicine.medscape.com article 296961-overview#a0104 http: naturalhealthperspective.com home riskfactors.html http: www.webmd.com digestive-disorders celiac-disease eating-plan-for-celiac-disease http: www.healthhype.com left-vs-right-sided-heart-failure-differences-in-signs-symptoms.html http: allnurses.com general-nursing-student rt-vs-lt-263736.html http: www.lbcma.org.uk newsArticles NAhearing.asp http: www.comeunity.com disability speech communication.html http: kidshealth.org parent system ill speech_therapy.html#

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