INTRODUCTION

A.

Overview of the Study

Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through. There can be different causes of intestinal obstruction. In the case of patient B.V., the cause is mechanical specifically constricting bond at splenic area. The blockages can occur at any point along the small or large intestine. They are more common in the small bowel. Over time, food, liquid, and gas build up in the area above the blockage. This can cause abdominal pain and swelling. Symptoms of intestinal obstruction may also include vomiting, diarrhea, and fever. Complications from an untreated obstruction can include strangulation, which is cutting off of the blood supply to part of the intestine that may lead to necrosis. Some causes of bowel obstruction may resolve spontaneously but many require operative treatment. In adults, frequently the surgical intervention and the treatment of the causative lesion are required. In malignant large bowel obstruction, endoscopically placed self-expanding metal stents may be used to temporarily relieve the obstruction as a bridge to surgery, or as palliation. Additionally, acute appendicitis is defined as a sudden inflammation of the inner lining of the vermiform appendix that spreads to its other parts with the main symptom of abdominal pain. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. Some research suggests that appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract. However, if the inflammation and infection spread through the wall of the appendix, the appendix can rupture. In Ruptured Appendix, infection can spread throughout the

abdomen which poses risks for peritonitis, systemic infection, and shock. Typically, appendicitis is treated by Appendectomy and can be done two ways. The older method, called laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time. The patient is a 60-year old male Filipino who was admitted on February 27, 2012 at Sabal Hospital with chief complaints of abdominal pain and distention. He had a diagnosis of Mechanical Intestinal Obstruction Secondary to Constricting Bond at Splenic Area, Acute Appendicitis.

B.

General Objectives

At the end of this case presentation, the nursing students will be able to know and understand the different nursing concepts and principles related to the condition concerning the disease of patient B.V. The presenter also aim to illustrate the implemented procedures and interventions learned to provide proper nursing management that is suitable to the patients condition, and to apply the values of a nursing student having competence and commitment.

C.

Specific Objectives

1. Present a thorough assessment and accurate data based on: a.1 The statements made by the patient and significant other a.2 The observations made by the student nurse during hospital duty with the patient a.3 The data gathered from the patients chart 2. State the basic anatomy and physiology of the body systems involved in the patients disease condition 3. Trace the pathophysiology of the disease experienced by the patient

4. Recognize and present the actual medical management for the patient given by his physician and apply the ideal medical management to serve as a basis for improvement of his condition 5. State the different pharmacologic agents prescribed and know its effects on the body and to the patient as a whole 6. State the individualized nursing care plan based on the nursing diagnosis identified related to the signs and symptoms manifested by the client 7. Present the discharge plan considering the patients condition and prioritize his needs to achieve a good prognosis

D.

Scope and Limitation

The study focuses on the assessment, anatomy and physiology, concept map, medical and surgical management, priority nursing care plans, discharge plan, prognosis, recommendation and conclusion of patient B.V.s disease condition which were all based on the assessment and duty days from February 29 March 1 and 2, 2012. The data obtained in this study were based on what were verbalized by the patient and his significant other and on what the student nurse have seen and observed during the assessment, supported by the patients chart. The nursing care plans, medical management, and prognosis were solely prepared for the patients condition and to promote individualized care.

Health History A. Patient history Name: violeto bajas Gender : Male Age : 60 years old Civil status: married Birth date: 5/3/1951 Birth place: Cagayan de Oro City Address: blk 32 Lot 23 phase 3 bugo cagayan de oro city Occupation: retired army Monthly income: 26K/month(10k pension + 16k daughter salary call center ) Name of informant: patient himself Admitting diagnosis: complete mechanical intestinal obstruction Final diagnosis: mechanical intestinal obstruction secondary to bond at spleen area, acute appendicitis Operation: Ex. Lap. Decompression enterotomy, release of constricting bond, adhescolysis, appendectomy repair of tear jejunum Attending physician: Dr. ferrarrin

B. Medical History Mr. bajos was admitted at Norther Mindanao medical center last 2010 due to head aches, dizziness, chest pain the doctor dinal diagnosis is angina pectoris He said to be hereditary beacese his father was also disnos with angina. Now he maintaines his medication, exercise and diet. The patient denies allergies to any medications, foods or animals. The patient claims that he only suffered from two common childhood illnesses, chicken pox and measles, when she was a kid. According to him he was completely immunized when he was a child as evidence by scars on the patients left and right deltoid

C. History of present illness 1 month prior to admission patient is experiencing abdominal pain he use to manage by putting efecasecnt oil and paracetamol to relief from pain. 2 days prior to admission patient suffered from abdominal pain at his right lower quadrant abdomen with abdominal distension. He manage to take paracetamol to relieve pain bit it was not subside until he decide to be admitted at COMC, there the doctor immediately perform operation they rule out there was adhescoulysis of GI tract jejenom and rupture of appendix.

VI. NURSING MANAGEMENT NURSING SYSTEM REVIEW CHART

Name: violeto bajas Date: 2-29-12 Temp.:37C Pulse Rate: 66 BPM Resp. Rate: 26CPM BP: 120/80 mmHg Height: 54 Weight: 70kg INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X].

EENT: [] impaired vision [ ] blind [ ] pain [ ] reddened [ ] drainage [ ] gums [] hard of hearing [] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose throat for abnormalities. [ ] No problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood breath sounds, comfort

NGT NGT remove during 3-1-12

pain with pain scale of 7 pain with pain scale of 6 pain with pain scale of 7 D5NmiL at 30 gtts/min infiltration peritonitis peritonitis peritonitis incisional wound with pin rose incisional wound with pin rose incisional wound w/o pin rose FBC FBC remove during3-1-12

[ ] No problem

CARDIOVASCULAR: [ ] arrhythmia [ ] tachypnea [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sound, rate, rhythm, pulse, blood pressure. Circulation, fluid retention, comfort [x] No problem GASTROINTESTINAL TRACT: [ ] obese [x ] distention [ ] mass [ ] dysphagia [ ] rigidity [x] pain Assess abdomen, bowel habits, swallowing bowel sounds, comfort. [] no problem GENITO-URINARY AND GYNE: [ ] pain [ ] urine color [ ] hematuria [ ] discharge Assess urine frequency, control, color, odor, Comfort, gyne bleeding, discharge [x] No problem [ ] vaginal bleeding [ ] nocturia

NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor, function, sensation, LOC, strength Grip, gait, coordination, speech [x] No problem MUSCULOSKELETAL AND SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [x ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] deformity [x ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ x] pain [ ] ecchymosis [ ] diaphoretic [ x] moist Assess mobility, motion, gait, alignment, joint function Skin color, texture, turgor, integrity [] No problem

Constipation

Legends : 2-29-12 3-1-12 3-2-12

NURSING ASSESSMENT II
SUBJECTIVE COMMUNICATION: [] Hearing loss [ ] Visual changes [ x] Denied OBJECTIVE

Comments: ok raman akong pananaw og pang dungog. As verbalized by the pt.

[x ] glasses [ ] contact lens [ ] Speech difficulties R Pupil size: 3mm Reaction: PERRLA

[ ] languages [ ] hearing aide L

OXYGENATION: [ ] Dyspnea [ ] Smoking history [ ] Cough [ ] Sputum [x] Denied CIRCULATION: [ ] Chest pain [ ] Leg pain [ ] Numbness of Extremities [x] Denied NUTRITION: Diet: Lugaw []N []V Character [ ] recent changes in Weight, appetite [ ] swallowing difficulty [x] Denied

Comments: Wala man koy problema sa akong pag-ginhawa. As verbalized by the pt.

Respiration: [x] regular [ ] irregular Describe: Pt. has normal cycle per min. of 26 cpm R: symmetric breathing sound to L - lung L: symmetric breathing sound to R - lung

Comments: Wala man koy gibati na sakit sa akong dughan ug sa akong tiil, malihok man nakoako rang tiyan. As verbalized by the patient.

Heart rhythm [x] regular Ankle edema: none

[ ] irregular

Pulse Carotid Radial Dorsal Pedis Femoral R + 66bpm + no opportunity L + 66bpm + no opportunity Comments: Pulse has low beat per min. of 66bpm *If applicable [ ] dentures Full Upper Lower [] [] [x] none Partial [] [] With patient [] []

Comments: Lugaw ra man akong gakaonon, mao may sugo sa doctor. As verbalized by the pt.

ELIMINATION: Usual bowel pattern Urinary frequency Two times a day 3-5 per day_____ [ ] constipation [] urgency Remedy [] dysuria Increase fluid intake [] hematuria Date of Last BM [] incontinence 2-29-2012 [] polyuria Diarrhea Character [x] Foley in place Brown stool [] denied MGT. OF HEALTH & ILLNESS: [ x] alcohol [] denied ( amount, frequency) ocation lang [ ] SBE Last Pap Smear: NA LMP: NA

Comments: There is abdominal distension during palpitation. For bowel sounds it has a gurgling noise. The pt. have complaint regarding to pain and distention

Bowel sounds: Audio bowel sounds. Abdominal distention present [ x] yes [] no Urine* (color consistency, odor) Yellowish in color and odorless, aromatic odor. *if Foley is in place?

Briefly describe the patient's ability to follow treatments (diet, medication, etc.) for chronic health problems (if present).

The pt. follow the treatment specially in his diet because that time when I observe he is taking his, he eats at the right time for his right route of his medication.

SUBJECTIVE SKIN INTEGRITY: [ ] Dry [ ] Itching [ ] Others [x] Denied ACTIVITY/ SAFETY: [ ] Convulsion [ ] Dizziness [x] Limited motion of joints Limitation in ability to [ ] ambulate [ ] bathe self

OBJECTIVE

Comments: Wala man koy mga bunga singot. As verbalized by the patient

[ ] dry [ ] flushed [x ] moist

[ ] cold [ ] warm [ ] cyanotic

[ ] pale

*rashes, ulcers, decubitus (describe size, location, drainage, color, and odor) There is no rashes ucer and decubitus

Comments: kong naa ko gusto kwaon ipasugojud nako kay gapanakit na akong bukogtungod sa tigulang na pud ko ug kong maligo, kilangan jud naa uban As verbalized by the patient

[ ] LOC and orientation: The pt. was oriented in the place. Gait: [ ] walker [ ] cane [ ] other [ ] steady [ ] unsteady [ ] sensory and motor losses in face or extremities: The pt. is conscious, has good sensory [ ] ROM limitations: The pt. has limitation in activity, when

[ ] other [ ] denied COMFORT/ SLEEP/ AWAKE: [ x] Pain (location , Frequency, Remedies) [ ] Nocturia [ x] Sleep difficulties [ ] Denied COPING:

he wants to out in the bed; he needs to have an assistant.

Comments: sakit ka au akong tiyan ako magayo nlng ko og tramadol sa nurse kay sakit gyud. As verbalized by the patient

[x] facial grimace [ x] guarding [ ] other signs of pain: There is pain, when he is frowning his face when he does he want to do that thing. [ ] side rail release form signed (60+years)

Occupation: retired army Members of household: (4)seven members Most supported person: his wife merly and daughter mary

Observed non- verbal behavior: When he does not want to do that things, he just frown as his facial grimace, and also if there is signs of pain. The person and his phone number that can be reached any time: 0929269741

DIAGNOSTIC WBC

NORMAL ACTUAL RESULT RESULT 5, 000- 10, 21, 900 mm3 000 mm3

NURSING IMPLICATION High-indicates infection

NSG. RESPONSIBILITY >Instruct patient to increase intake of Vitamin C and increase fluid intake >Administer antibiotic as ordered

HGB RBC HCT

13.0-16.0 g/dL 4.5-5.3 million/mm 37.0-47.0 %

12.8 g/dL 4.99 million/mm3 37.8%

Normal Normal Normal

MCV

82.0-95.0

74.0 fL

Low-indicates anemia

>Instruct patient to increase intake of Vitamin C and increase fluid intake

MCH

27.0-31.0

26.2 pg

Low-indicates Iron >Instruct patient to deficiency increase intake of foods high in iron such as green leafy vegetables

Differential count Lymphocytes 25-33% 10 % Bacterial infection >Instruct patient to increase intake of Vitamin C and increase fluid intake >Administer antibiotic as ordered

Monocytes Eosinophils

3-7% 1-3%

1% 1%

Bacterial infection normal

Doctors Order
2-28-12 2-29-12 3-1-12 3-2-12 Clear liquid Turn sides every two hours D5NM iL @ 40 gtt/min Continue meds soft diet Mobilize drain May ambulate D5NM @ 40 gtts/min Continue soft diet . Pull out NGT and FBS To follow D5NM iL @ 40 gtt/min Apply abdominal binder May ambulate Dulcolax now Dressing ambulate Minmize GI stimulation and promote recovery from paralytic ileius Prevent pneumonia Electrolyte and nutrient replenisher Prevent infection and pain Practice GI to work slowly To drain drainage and prevent infection Prevent thromboplibitis Electrolyte and nutrient replenisher Practice GI to work slowly Prevent infection and they are already functional Electrolyte and nutrient replenisher Provide constriction in the abdomen Prevent thromboplibitis Provide defication Cleansing wound to prevent infection Prevent thromboplibitis

anatomy
Human Digestive System The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules). On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down. In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food. In the large intestine - After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, andKlebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus.

THE APPENDIX In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum), from which it develops embryologically. The cecum is a pouchlike structure of the colon. The appendix is located near the junction of the small intestine and the large intestine. The term "vermiform" comes from Latin and means "worm-shaped".The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the appendix is usually between 7 and 8 mm.The appendix is usually located in the right iliac region, just below the ileocecal valve (designated McBurney's point) and can be found at the midpoint of a straight line

drawn from the umbilicus to the right anterior iliac crest. The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum.

The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. During the first few years of life, the appendix functions as a part of the immune system, it helps make immunogobulins. But after this time period, the appendix stops functioning. However, immunoglobulins are made in many parts of the body, thus, removing the appendix does not seem to result in problems with the immune system. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed.

Schematic Pathophysiology of Acute Appendicitis

Predisposing Factors: Gender (more common in males) Age (10 to 30 y/o)

Contributing Factors: Diet; Low-fiber, high in Carbohydrate Swollen lymph glands (on the wall of the appendix)

Fecal mass
Ingestion of foreign bodies (may be in form of small swallowed beads, grain of fruits, cereals, fish bone or sand)

Precipitating Factor Occlusion of Appendix by Fecalith (Fecal Stone) Appendiceal mucus secretions continue Accumulated intraluminal fluid Congestion Increased ILP in the appendix venous return Decreased blood supply in the appendix Decreased Oxygen supply in the appendix Mucosal ischemia decreased WBC and other fighters of infection Luminal bacterial overgrowth

Normal bacteria found in the gut invade the appendix Disruption of Cell Membrane of Appendix Start of Inflammatory Process

Release of Chemical Mediators to area

Histamine, prostaglandin, leukotrines, Bradykinin Swelling of Appendix Prostaglandin, Bradykinin Pain in the RLQ Acute pain Interleukin-1 Inc. WBC N&V risk for deficit Fluid volume

Stimulation of Vagus nerve

Neutrophils

Activation of the vomiting center in medulla

suppression of sympathetic of GI function

Pus Formation

Anorexia Risk for imbalance nutrition less than body req.

Appendix rupture Peritonitis

Inflammation of Appendix (Appendicitis) Appendectomy Tissue Trauma Open Wound Impaired tissues integrity risk for infection Inflammation response Release of prostaglandin/bradykinins stimulation of CNS pain in surgical sites Cellular injury stimulation of nociceptor in the dermis

VII. NURSING MANAGEMENT Actual Nursing Management (SOAPIE) Dili kaayo ko makatulog kay sige lang ko mata mata. As verbalized by the patient. - Body weakness Dark circle under eyes Sleep pattern before from 11pm 5-6am. Sleep pattern during hospitalization 2 3 hours in the evening. -

- Reports difficulty in falling asleep. Sleep pattern disturbance r/t environmental changes psychological stress. Long term: patient will not be disturbe from sleep Short term: patient will be able to asleep

Giving health teaching regarding with his changing in life style. Discuss the purpose for the pt.s knowledge.

- Monitor vital signs. 1. Foods and fluid that containing caffeine has been restricted. 2. Family members of the pt. have been instructed to continue guide and support for the pt. usual bedtime rituals. 3. Family members have been instructed to always provide a quite

environment and do comfort. 4. The pt. must participate to some exercise for his regular activity to aid in stress control and to release of energy. 5. Has been recommended inclusion of bedtime shack for his paper diet. At the end of 3 days and 8 hours the pt. will be able to have been

instructed to experience good sleep pattern as evidence of sleeping for about 8 hours.

S O

sakit ka au akong tiyan. As verbalized by the patient Pain scale of 7 Gurding his abdomen Facial grimace

A P I E

Pain, Acute r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision (Appendectomy) Long term: relief from pain Short term: minimize pain experience 1.instructed to have relaxation techniques 2. divert attention away from pain 3.removed any stimuli that contribute to pain At the end of 8 hours of giving effective nursing intervention and health teaching the pt. was able to minimize pain experience.

S O

dili ka ayo ko confortable sa akong samad. As verbalized by the patient. - disrupted skin layers -wound area is warm to touch -abdominal distention

Impaired Skin Integrity r/t disrupted skin layers secondary to surgical incision Long term: Physical assessment

Short term: 1. I instructed the patient to provide small, frequent feedings. 2. I encouraged the pt. to take daily cleansing of wound 3. I was encourage the pt. avoid unnecessary movement or activity. 4. I instructed patient to increase intake of foods rich in protein, minerals and vitamins 5. Instructed patient to have adequate rest and sleep 6. I instructed patient to have bath 7. I teach and assist the client in the following: a.supporting the surgical site when moving b.Splinting the area when coughing, sneezing, or vomiting

At the end of 8 hour of giving nursing intervention and health teaching the pt. will demonstrate proper cleansing of wounds.

S O

Naa nana sa akong samad presence of wound (surgical incision) at the right iliac region >disruption of skin layers >(+) slight swelling at the incision site > wound area is warm to touch Risk for Infection r/t surgical procedure (Appendectomy) At the end of the shift patient will not be infected 1. I instructed to have daily wound dressing

A P I

2. I imparted and Emphasize good hand washing technique for all individuals 3.
E coming in contact with the patient instructed to have Change wound dressings as indicated, using aseptic technique

4. At the end of the shift patient will wound will not be infected

HEALTH TEACHING MEDICATION EXERCISE TREATMENT OUT PATIENT Instructed patient to continue his medication even at home Nitro patch He must exercise daily to strengthen his body and to be healthy. Exercise that is fit to him walking and then jagging in order for him not to feel lazy. He must follow the doctors order regarding for his medication for easily and continuously recover and take his daily exercise so that he can maintain his healthy body. He must continue to take his medication as doctors recommended and also continue his daily exercise. Encourage to increase fluid intake and vit. C, avoid in crowded places and must continue check up once in a month. He must need a proper diet in order for him to stay healthy so that he can manage to take his daily medication and exercise.

DIET

X. EVALUATION AND IMPLICATIONS Implementation which serves actual interventions I proven to be successful in the patient course of care. The patient cooperated and participated in the instruction given to him, by which I can proudly say that our nursing intervention was good.

I also learned to humble myself even more. I also realized that I need to thank God for giving me a healthy life and letting me care for those people in need. Indeed, nurses are given a healing gift by God. This care study has given me a lot of overview on the isolation setting. I was also given the chance to care for a patient in two days. For those days various nursing functions was rendered and it gave me the opportunity to develop and enhance my nursing skills. My over all general ward exposure at Medical Ward, Northern Mindanao Medical Center was a great one. Its a well learned exposure for us.

Organization/Grammar/Bibliography Kozier, Erb, Berman, Snyder, FUNDAMENTALS OF NURSING, 7th edition published by Pearson Education Inc. Copyright 2004, Wilson, Shannon, Stang, NURSES DRUG GUIDE 2004, Philippine edition published by PEARSON EDUCATION SOUTH ASIA PTE LTD. Copyright @ 2004, volume 1 & 2, pp.86- 89, 270- 271 Joyce Young Jonhson, R, PhD, Handbook for Brunner & Suddarths: TEXTBOOK OF MEDICAL- SURGICAL NURSING, 19th edition copyright @ 2004 by Lippincott Williams & Wilkins Smeltzer, Bare, Brunner & Suddarths, TEXTBOOK OF MEDICAL SURGICAL NURSING, 10th edition, volume 1 Marilynn E. Doenges, RN, BSN, MA, CS, Mary Frances Moorhouse, RN, BSN, CRRN, CLNC, NURSING CARE PLANS: Guidelines for Individualizing Patient Care, 6 edition, copyright @2002 by F.A. Davis Company, pp.304- 328