Essay: MENINGOCOCCAL MENINGITIS

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  • MENINGOCOCCAL MENINGITIS
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Meningitis is a serious inflammation of the meninges, the thin, membranous covering of the brain and the spinal cord. Meningitis is most commonly caused by infection (by bacteria, viruses, or fungi), although it can also be caused by bleeding into the meninges, cancer, disease of the immune system, and an inflammatory response to certain types of chemotherapy or other chemical agents. “The most serious and difficult-to-treat types of meningitis tend to be those caused by bacteria. In some cases, meningitis can be a potentially fatal condition” (Brown & Edwards, 2005 pg 1521).
This assignment would focus on a meningococcal meningitis patient and would discuss the client’s history, a diagrammatic representation of the pathophysiology of the underlying disease and the physical assessment involved. It would also include the nursing management provided to the client.
Patient’s Health History
Date and Time of History
On 9th February, 2016 at 1400hrs the health history of Mrs. X was obtained from her husband.
Identifying Data
Name : Mrs. X Education level: secondary school (Form 6)
Age : 34 years Religion: Methodist
Date of Birth : 17/12/1977 Phone contact: 8395165 (husband)
Gender : Female Emergency contact: 8395165 (husband)
Marital Status : Married
Occupation : Domestic Duties
Race : Fijian
Present address : Bua village, Labasa
Source of History of Referral
The above information about Mrs. X was obtained from her husband. During the cause of the interview Mrs. X was fully aware of what was being asked and responded well.
Chief Complaint
As stated by the husband, Mrs. X was unable to tolerate meals for 3/7 days, had body pains, felt dizzy and had severe headache.
Present Illness
Currently, Mrs. X was admitted in the hospital on the 20th May, 2012 when she developed severe headache, mostly fontal and some retro-orbital pain as well, she started vomiting ≈ 6 episodes/ day.
Past Medical History
• At the age or 21 years (1998), Mrs. X was hospitalized as a result of being diagnosed with dengue fever and having asthma.
Psychiatric history
• Mrs. X family there is no mentally ill person and everyone in the family mentally health.
Gynae History
• Loop inserted in 2003, married with two kids.
• No history of miscarriages.
Family History
• Mrs. X had childhood asthma and is allergic to penicillin.
Social History
• Non smoker and kava drinker.
• Alcohol – a year ago left drinking.
• Mrs. X is Married
• Mrs. X is living in a wooden house with his husband and two kids in Bua village and the house is well ventilated and clean
• Mrs. X’s parents are alive there are living in Suva
Medical Diagnosis
 Acute Febrile Illness
 R/o Septicemia
Pathophysiology (Meningitis)
The infectious agents (that is, bacteria, virus, fungus, and parasite) enter the central nervous system (CNS) from the nasopharynx and via the respiratory tract through the bloodstream or via the nerves or by direct contiguous spread from the adjoining structures and replicate an uncontrolled fashion resulting in meningeal inflammation (Brunner & Suddarth Medical and Surgical nursing Pg: 1145).
The diagram on the next page shows the pathophysiology of bacterial meningitis
Physical Assessment (are relevant to the disease)
General Survey (Subjective Data)
Complete patient history taken as verbalized by husband:
 Client unable to tolerate meals for 3/7 days, felt dizzy, had body pains and had severe headache.
 Relatives asked about photophobia of patient and noting patient’s behavior towards light indicated fear of light
Objective Data
 Temperature is elevated (fever)
 Pulse is high (tachycardia)
 Respiratory rate is high (due to tachypnea)
 Blood Pressure is low
 Level of Consciousness: drowsy, abnormally sleepy (due to cerebral edema)
Neurological Assessment
 Sight examined through Snellen’s Chart, showed diplopia.
 Pupils examined with penlight showed impaired response to light (absence of papillary responses)
 Hearing test conducted: hearing loss noted in both ears
 Facial muscles checked by observing expressions, facial muscle weakness noted.
Musculoskeletal Assessment
 Neck palpated and stiff neck and pain noted
 Back palpated and back pain noted
 Positive Brudzinki’s sign noted. This is the flexion of the hip and knee in response to forward flexion of the head indicating positive Brudzinki’s sign. (Berkow, 2002 pp.90).
 Positive Kernig’s sign noted; this is the inability to completely extend the knee beyond 135 degrees without causing pain. (Douglas 2006 pp.543).
 Opisthotonos evident; severe arching of the neck and back seen which is caused by the extensor muscle spasm.
Nursing Investigation
• Full blood count
• Coagulation screening
• Blood culture
• Arterial blood gas
• Lumbar puncture
Nursing Diagnosis
Diagnosis Causes Subjective objective
Anxiety • stress Patient is unable to sleep due to pain. Patient is restless due to pain.
Acute pain • Stiffness neck Mrs X complaining of neck vision and stiffness Patient is unable to move neck and which is should by her facial expression that she is experiencing
Impaired physical activity • Physical weakness According to relative patient is unable mobilise due to pain Patient is able to moblise slowly but experiencing pain.
Disturb
Sleep- pattern • pain
• stress Mrs X complaining of pain that she is not able to sleep Patient is not able to sleep due to pain and it is expressed by facial expression.
Ineffective breathing pattern • Pain
• stress Mrs X is not able to breath effectively due to pain Patient is unable to breath properly due to experiencing of pain
Nursing problem
Problem Planning Implementation Evaluation
Anxiety related to stress The patient should learn to behavior to relieve stress and anxiety Teaching method to overcome stress and relaxation techniques The patient clearly demonstrated behavior to relieve stress and overcome anxiety.
Impaired physical mobility To increase strength and to maintain skin integrity Encourage patient to mobilise slowly and teaching some range of motion exercises. Patient is able move body parts slowly to avoid any skin integrity and able to gain strength.
Impaired breathing pattern To make effective breathing pattern Provide oxygen to maintain 100% oxygen saturation in room temperature. Patient is able breath properly and oxygen saturation is maintained in room temperature.
Sleep disturbance related to a pain Pain free Give sedation to relive pain. Patient is able to sleep properly after giving sedation
Daily nursing management
Independent Dependent Collaboration
 Reassurance and psychological support.
 Nurse the patient semi-fowler position
 Monitor four hourly signs such as temperature, blood pressure, respiration, pulse and oxygen saturation
 Monitors signs of complication.
 Assisting in patient to attain personal hygiene such as shower, shaving, oral care.  Medical doctor to prescribe drugs.  Dietician- to advice on diet depending on patient condition.
 Radiologist – to do scan and x-ray on particular area that is affected.
 Pharmacist – to give drugs as prescribed by the doctor.
 Family members- involve family members in decision making about the patient condition.
 Laboratory lab- to do bloods such as full blood count, urea and creatinine level in the body.
Nursing Management
• The level of consciousness (neurologic assessment) and the temperature were closely monitored for this particular disease as this would highlight to us the status of the infection and would allow us to take effective interventions to assist in the treatment of meningitis.
• The intravenous site was often checked to avoid infiltration and phlebitis and the patient was also closely monitored for any adverse effects of the intravenous medications administered. The patency of the intravenous line was also closely monitored to ensure that the client would receive adequate intravenous fluids which would enhance the treatment procedure.
• Part of the nursing management was to monitor the fluid balance of Mrs. X. We had to ensure that she had enough fluid intake in order to avoid dehydration also keeping in mind that fluid overload did not occur which would leave her vulnerable to cerebral edema. Thus, an effective monitoring of fluid input and output was needed to provide the appropriate amount of fluids and at the same time avoiding any complications regarding intravenous therapy.
• Proper positioning of a client was also a major priority. She was positioned carefully and comfortably to prevent joint stiffness and neck pain and was often re-positioned according to schedule (2 hourly) to maintain patent blood circulation in her body and to prevent any pressure ulcers from occurring.
• The patient was also given all her medications on time to assist mostly in pain relief and was also assisted with her anxiety by having short chat sessions and casual talks. Providing constant reassurance also played a major part in helping to allay Mrs. X’s anxiety issues.
• Another important part of nursing management was to maintain the clients’ personal hygiene. This included oral care and also sponge baths twice daily. This would help to avoid nosocomial infections and would also have a positive psychological effect on the patient.
Evaluation
In evaluation Mrs. X was able to get better. She is was able to understand about the disease of meningitis cause and effect on the patient condition. Her vital signs were getting in normal range. She was reporting decrease episodes of dizziness, fatigue and was able to take part in desired activities. Mrs. X was able to verbalize much clearly than before and able to move her head slowly and gently. She was able to overcome stress and anxiety and lastly she was able to attain her personal hygiene and oral care without and assistance and was fit enough to go home.
Conclusion
Therefore, it can be concluded that for meningitis to occur, infectious agents travel along respiratory tract from nasopharynx to cause the inflammation of the covering of the brain, meningitis. Appropriate physical assessment is to be performed in order to gain correct and thorough knowledge of the problem at hand. The physical assessment comprised of our subjective and objective data. These would include whatever information that we had gathered from our client and our own observations. Observations that were made in relation to the particular disease at hand were neurological and musculoskeletal assessments. Effective nursing management is one of the key components in the recovery of any ill person and these were also thoroughly discussed in this assignment. With the aid of appropriate treatment orders in correlation with competent and effective nursing skills\\management Mrs. X was discharged in 5 days with full recovery from the disease. Thus, it is can be said that having competent nursing skills and the ability to effectively manage a client is just as important as having a major operation done by a qualified surgeon when looking at the big picture, which is the holistic recovery of the client. (Danielson 2009, pg.10).
REFERENCES
Berkow, P. (2002). Neurological Assessment: A Clinician’s Guide, 1st Ed (Physiotherapist’s Tool Box). New South Wales: Pearson Education Australia.
Brown & Edwards (2005) Lewis Medical- Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier, Australia pg: 1523.
Brunner & Suddarth (1998). Textbook of Medical – Surgical Nursing (6th Ed) Washington DC.pg: 1145- 1152.
Danielson, O. (2009). Health & Physical Assessment in Nursing. (2nd Ed). Melbourne: Oxford University Press.
Douglas, L. (2006). Neuropsychological Assessment. New York: McGraw-Hill.
Glanze, W.D., Anderson, K.N. & Anderson, L.E (1990). Mosby’s dictionary: medical, nursing and allied health (3rd Ed.). St Louis: The C.V. Mosby Company
Pregnancy Induced Hypertension (PIH)
Introduction
Making a decision to have a child it is momentous. “Birthing is the most profound initiation to spirituality a woman can have” (Hakim, 2014). This case write up is about pregnancy induced hypertension using the nursing process. This case is chosen from labour ward. The main components of this essay will include the subjective data, objective data and the nursing management. Using the nursing process the nursing problem, diagnosis, planning, implementation, evaluation and the rational will be tabulated to have a comprehensive data and enabling the nurse to independently find out nursing problems and aid in providing the best medical care and treatments to clients suffering from pregnancy induced hypertension. Pregnancy induced hypertension (PIH) is a condition in which vasospasm occurs during pregnancy. “Signs of hypertension normally >140/90 mmHg that presents after the 20th week of pregnancy, proteinuria and edema develop. It is unique to pregnancy and occurs 5% to 10% of pregnancies in the United States” (Pillitteri, 1999). This condition is associated with poor calcium or magnesium intake. Pregnancy induced hypertension tends to occur more frequently in primiparas younger than age 20 years or older than 40 years. Moreover other factors include mothers from a low socioeconomic background perhaps because of poor nutrition, women who have had five or more pregnancies, women of colour, women with multiple pregnancies and women with hydramnios. Mothers with underlying disease such as heart disease, diabetes with vessel or renal involvement and essential hypertension are at a high risk of developing PIH. Some associated complication of PIH include intrauterine fetal growth restriction (IUGR), placenta abruption, superimposed pre-eclampsia and worsening hypertension leading to severe hypertension and risks of stroke, cerebral vascular accident(CVA) and organ damage.
Subjective Data
Biodata
Name: Mrs. X Marital Status: Married
Fathers Name: Mr. Z Gravida: 1 Para: 0
Age: 24 years Occupation: Domestic
Religion: Muslim Duties
Race: Indian Education: Form 6
Temporary Address: Vunika, Labasa Husbands Name: Mr. X
Gender: Female Occupation: Digger Operator
Age: 26 years
Functional health problem/pattern
Mrs. X is able to mobilize freely without assistance. Voids six to seven times daily and opens bowel once or twice daily. Is able to verbalize freely and clearly. Perform self-care such as oral care, hair care, perianal care and has bath twice daily. Is clean and is neat appearance. Wears cotton clothing and wears non slippery flat foot wear.
Chief Compliant
Mrs. X attended her first antenatal clinic on her booking day. Like every other mother she was called on clinic dates her weight was taken, she was given dipstick and her bloods were done. She was sent for scanning and her blood pressure was checked. She had fluctuating blood pressure and also her fetus was not in accordance with her weeks of gestation. Following results and blood pressure it was not lowering and she was found to have pregnancy induced hypertension.
History of Present Illness
When Mrs. X was a known case of PIH she was admitted in hospital five times for PIH assessment where every time she presented herself in hospital with complaints of edema, not wanting to eat, feeling weak, feeling tired and having perfused sweating. This was due to Mrs. X not wanting to attend to antenatal clinic on her clinic dates because of long waiting lines she goes home early without being checked by doctor and getting medication and advice on diet, light exercise and getting educated on danger signs like fetal movements and kick charts. Mrs. X was recognized to have intrauterine growth retardation which was severe. Every time when Mrs. X was admitted she complained of going home. Therefore doctors and nurses wrote a letter for not being held responsible for any mishap that occurs to Mrs. X and her fetus as it was all her individualized decision to leave hospital and go home. It was Mrs. X own neglection of herself, her fetus and her health. Mrs. X has blood pressure reading usually of 160/100 mmHg or greater, her scan results were always fetus not in accordance with weeks of gestation. Mrs. X was a primipara. Tests included dipstix to test urine, 24 hour urine and creatinine ratio was >30mg/mmol. Mostly her pregnancy induced hypertension assessment was not successful as Mrs. X always went home in the middle of the assessment. On every clinic she had scan and cardiotocogram. Her medication dose changed upon assessment on blood pressure. Her maternal side is known case of hypertension.
Objective Data
Mrs. X presented herself with edema, face and hands had puffiness which was palpated over bony surfaces. Swelling spread to lower extremities. She had severe epigastric pain and nausea and vomiting possibly due to abdominal edema. Other symptoms included headache, visual disturbance (flashing light). Her blood platelet count was low, abnormal liver function,
liver tenderness, clonus (intermittent muscular contractions and relaxations), papilloedema and haemolysis elevated liver enzymes and low platelet count (HELLP) syndrome. Her blood pressure was 150/90 mmHg. Due to these symptoms Mrs. X was stressed and unhappy and worried about her health and her baby.
Investigations
Scheduled antenatal appointments, at each appointment blood pressure was recorded, urinalysis with proteinuria and assessment of fetal growth by symphysis-fundal height (SFH). Ultrasound fetal growth and amniotic fluid volume assessment between 28 and 30 weeks and umbilical artery Doppler velocimetry between 32 and 34 weeks. Urine sample and 24 hour urine collection to quantify the proteinuria (>300mg) and protein to creatinine (>30mg/mmol). Twice a week the following tests were monitored: kidney function, electrolytes, full blood count, transaminases and bilirubin. Full blood count to observe for platelet consumption and haemolysis. In PIH the haemoglobin concentration can be raised (>120g/l) due to haemoconcentratrion. Urea and electrolytes to assess renal dysfunction as there will be raised serum creatinine >90umol/l and liver transaminitis. Assessment of fetal wellbeing by ultrasound to monitor growth and volume of amniotic fluid and doppler velocimetry of the umbilical arteries. Weight is monitored with cardiotocogram and mother asked about fetal movements and kicks.
Personal History and Drug Use
Mrs. X had a good mutual understanding between her and her partner. She always had her maternal and paternal support whenever she came to hospital. She was an educated woman who was always smiling and conversing with others. But used to get tired and anxious due to waiting in ANC clinics. Relationships wither peers was evident when she used to talk to other antenatal clinic mothers of her same age, younger and older than
her. Mrs. X was the only daughter in her family. Mrs. X never suffered any sexual or physical abuse. No evident of physical illness was present during pregnancy. Had no insomnia and slept well. Mrs. X was a housewife and stayed home. Mental and motor development was evident where growth and development has taken place both physically and mentally. Mrs. X was never involved in illegal activities like violence and other acts of aggression. Mrs. X never had a police record.
Mrs. X was not allergic to any oral and intravenous medication. She had no addiction of any drugs and was on antihypertensive drugs.
Past Medical History
Mrs. X had no previous medical history. She was physically and mentally healthy and showed no signs of anaemia, malnutrition and other medical disorder and psychiatric disorders. She had a healthy appearance and her skin tone was well hydrated and well moistened.
Psychological Effect
Mrs. X is not a known case of mental condition. She has never been institutionalized for any mental assessment and treatment. There is nobody in her family that suffers from any psychiatric condition. There was no presence of psychiatric illness in her grandparents, aunts and uncles and any family member. Her paternal and maternal side had no cases of psychiatric disorder. In-laws also had no institutionalization and record of psychiatric disorder.
Family History
According to Mrs. X there was no history of diabetes, twins and tuberculosis in her family. However Mrs. X maternal side had hypertension. Which was evident in her being a candidate for pregnancy induced hypertension and hypertension after pregnancy. Where assessment my
medical care is needed to diagnose, observe and advice on the importance of diet and physical activity. No history of epilepsy was also evident.
Social History
Mrs. X is a non-smoker and non-alcoholic person. She never had grog and there was no signs and symptoms and history of drug use and abuse. She was a domestic housewife and was unemployed. Her hobbies included conversing with others, listening to music, watching series and movies, gardening, cooking and hanging out with friends and family members. Mrs. X had no nightlife and was not a very out going person. Mrs. X lives in a rural housing with her husband and in-laws in a well-ventilated house and sanitation is good. Her relationship with her parents, husband and in-laws is therapeutic. Her
Nursing Management
Nursing Problem Nursing Diagnosis Nursing Plan Nursing Implementation Nursing Evaluation
Altered tissue perfusion Altered tissue perfusion related to vasoconstriction of blood vessels -Ensure patent airway
-Assess for airway, circulation and breathing
-Maintain oxygen saturation
-Assess for signs and symptoms of cyanosis, perfused sweating and drowsiness. Independent
-Reassurance and psychological support
-Attach to cardiac monitor and monitor vital signs which includes oxygen saturation, temperature, pulse, respiration, blood pressure, glasgow coma scale and capillary blood glucose
-Nurse in semi-fowlers position
-Ensure all emergency equipments are working and emergency drugs are available with oxygen tubings and masks
-Administer oxygen as ordered by doctor
-Administer medication as prescribed and documented by doctor
-Ensure humidified oxygen is administered
-Provide oral hygiene and personal hygiene
-Monitor oral hydration and urine output and bowel movements
-Administer intravenous hydration as charted in nursing care plan
-Diet to be low salt and low fat diet
-Promote bed rest
-Monitor fetal well-being by doing CTG and monitoring kick charts
Dependent
-Doctor for ward rounds to assess clients condition and chart and revise medication and intravenous hydration
– Doctor to do bloods like full blood count, urea, electrolytes and creatinine and liver function test
-Doctor to write scan forms
Collaborative
-Pharmacist for medications
-Radiologist for scan
-Dietician to advice mum on nutrition and diet
-Physiotherapist to teach simple breathing exercise and light exercise
-Counsellors to relieve mums stress and address other factors affecting her.
-Oxygen is maintained at 95% to 100% in room air
-Mum has nil complaints of drowsiness and perfused sweating
-Mum is able to maintain self-care and personal hygiene
-Vital signs are stable and is maintained within stable limits
Fluid volume deficit Fluid volume deficit related to fluid loss to subcutaneous tissue -Maintain hydration
-Reduce electrolyte imbalance
-Prevent hypovolemic shock
-Assess for signs and symptoms of hypovolemic shock Independent
-Reassurance and psychological support
-Monitor vital signs like oxygen saturation temperature, blood pressure, pulse, respiration rate, capillary blood glucose and Glasgow coma scale
– Monitor blood results and inform doctors accordingly
-Weight to be taken
-Monitor oral hydration and provide adequate nutrition
-Monitor urine output and bowel movement
-Administer intravenous hydration as charted
-Administer medication as charted
-Assist in self-care if needed
Dependent
-Doctor for ward rounds and assessing client, charting medication and intravenous hydration
-Doctor for doing bloods to monitor electrolyte imbalance and heamoglobin level
Collaborative
-Pharmacist for medications
-Dietician to advice mum on nutrition and diet
-Cleaners
-Ward attendants
-Involve close family members -Hydration is maintained
-No electrolyte imbalance
-No signs and symptoms of hypovolemic shock
-Mum is not in fluid overload
-Vital signs are stable and there is no signs of hypotension
Risk for fetal Injury -Risk for fetal injury related to reduced placental perfusion secondary to vasospasm -Monitor fetus heart rate
-Ensure fetus is not in distress
-Monitor fetal movements and kicks
-Ensure mum maintains a good nutrition
-Other risk factors like alcohol, kava and smoking is eliminated
-Advice mum on danger signs Independent
-Provide reassurance and psychological support to mum
-Explain the diagnosis to mum thoroughly
-Monitor vital signs of mum which includes temperature, pulse, respiration, blood pressure, oxygen saturation, capillary blood glucose and Glasgow coma scale
-Monitor fetal movements and kicks
-Monitor CTG and inform accordingly
-Follow up scan results
-High-protein diet
-Monitor mums airway, breathing and circulation
-Maintain bedrest
Dependent
-Doctor to write scan forms
-Doctor to assess fetus and maternal well-being
-Doctor to prescribe medication and intravenous hydration
-Doctors for PIH assessment
Collaborative
-Pharmacist for medications
-Radiologist for scan
-Close family members and friends
-Ward attendants
-Dietician to advice mom on diet
-Counsellors to counsel mom on harmful effects of alcohol, smoking and drinking kava
-CTG and fetus heart rate in accordance
-Maternal well-being in good and maintained
-Vital signs of mum is stable
-Nil fetus distress noted
Social isolation Social isolation related to prescribed bedrest -Encourage family support
-Allow family and friends to meet mum
-Involve mum in recreational and group therapy
-Provide a peaceful and therapeutic environment for mum to open up and converse
Independent
-Nurses to be friendly and smiling
-Nurses need to provide a therapeutic environment
-Nurses should be eager and readiness to listen
-Encourage mum to interact with others
-Monitor vital signs and refer accordingly
-Monitor self-care and assist if need be
-Maintain adequate hydration and nutrition
-Monitor input and output
-Follow doctors plan
-Maintain bed rest
Dependent
-On doctor for medication and other plans
Collaborative
-Counsellors to counsel mum on recreational activities like conversing with others, listening to music, reading scriptures and books, encourage family members to spend time with mum and keep her happy and also to visit her when she is hospital and take good care of a her at home
-Involve close family members and friends -Mum conversing well with other clients in hospital and also with staff members
-Mum is not isolated and is happy
-Mum has family members and friends who come to visit her and support her
-Nil signs and symptoms of social isolation evident
Summary
Pregnancy induced hypertension is becoming more evident in antenatal clinics in this era. Mrs. X had other complications apart from PIH which included not abling to deliver normally so she had a caesarian section and also her blood pressure reading was not lowering. After delivery blood pressure was monitored to diagnose if mum is hypertensive or no. Vital signs were taken hourly, medication was administered as charted and mum was under observation. Baby had a birth weight of 2.65kg and was healthy and had no other complications. During observation Mrs. X had blood pressure readings within normal range and did not have hypertension. Mrs. X was discharged with baby and had follow up clinic in maternal and child health clinic for baby in one week and post natal clinic in hospital for Mrs. X. Mrs. X was advised on diet as she can be a candidate for hypertension in the future and also Mrs. X was taught how to clean her surgical site using aseptic technique and was advised to clean at home.
Conclusion
To conclude it can be said objective data and subjective data with health history plays a major role in diagnosing problems. A thorough nursing assessment aids in better management of the client. Nursing process plays a major role in providing nursing care and managing clients.
Reference
Elder, R., Evans, K., & Nizette, D. (2013). Psychiatric and Mental Health
Nursing (3rd ed.). NSW: Mosby. Elsevier
Fraser, D. M., & Cooper. M. A. (2004). Myles textbook for midwives (14th
ed.). St, Loui, Mosby
Hakim, A. (2014). Top 40 Beautiful Pregnancy Quotes For You.
Mumjunction. Retrieved 14 April, 2016, from
http://www.mumjunction.com/articles/beautiful-quotes-about
-pregancy_002952/
Nizette & Elders (2014). Psychiatric nursing & mental health nursing (3rd
ed.). Mosby. Elsevier
Pillitteri, A. (1999). Maternal & Child Health Nursing (3rd ed.). Lippincott.
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