Professional Documents
Culture Documents
NURS-1228
Submitted by
Group A
Submitted to
02/27/2011
The patient is an 83 year old Caucasian female with NKDA who was admitted on
02/02/2011 with the diagnoses of: pneumonia, confusion, and bile duct cancer on standard
isolation precautions. Upon questioning the patient, she states “I fell and woke up here, they said
I have pneumonia.” After speaking to the patients’ daughter-in-law, her admission was noted to
be the result of a fall in the home of the patient on the day of admission. She had apparently lain
in the floor of her kitchen until another family member had concerns for her safety and came
over for a visit. When the family member had found her, she was disoriented, and short of
breath. The family member called an ambulance and she was admitted to the floor following an
x-ray, CT scan, peripheral IV insertion and labs drawn in the emergency room. The results of the
labs were supportive of the diagnosis of pneumonia as her WBC is 26.5K/uL on the date of
admission. The CXR confirms pneumonia. The patient is a retired LPN who has no religious or
cultural requests. She lives at home by herself and has family in the area that check on her
frequently. She is of full-code status, has a living will and her driver’s license states she is an
organ and tissue donor. She enjoys reading and her only response to assessing her stress was her
“family and career.” Her medical history consists of hypertension, a disorder in lubrication
which has causes her to have dry eyes, mouth, and joints, osteoarthritis, diabetes, and she has had
a myocardial infarction that was further diagnosed to congestive heart failure. Additionally she
has a history of cancer of the bile duct which required the surgical placement of a stent in her
growth in one of the ducts that carries bile from the liver to the small intestine” (Lewis 2007).
versus despair conflict and has shown to resolve this by possibly maintaining integrity as she has
MAJOR CASE STUDY 3
chosen not to undergo chemotherapy. Despite her fluctuating LOC, she has been classified as a
reliable historian as she answers questions directly and they appear identical to the history
provided in her medical record. She does not smoke or drink and does not engage in recreational
drugs. Her immunizations are up to date and it was further recommended to her that upon
discharge she should get a pneumonia vaccination and she declined to the opportunity.
On this clinical day, (02/07/2011) the patient was awake, alert and oriented to person and
place. She responded to questions with clear speech and she seemed rather agitated in her tone of
voice when she asserted “I’ve been in this bed for three days”. Her pupils are 3mm and are equal
bilaterally and after they reacted to light, they were then considered normal in accommodation.
Her affect appeared flat and all together emaciated. Her skin is pink, warm and dry with poor
turgor. Her temperature is 96.6 taken temporally. Additionally a few bruises are noted on the
tops of her hands. Upon inspection, no decubitis are found. Her Braden score is noted at 16
putting her at low risk for pressure ulcers. The patient has one incision on her upper-right flank
that is healing by primary intension as tissue surfaces were approximated and there is minimal
tissue loss. The scar is 3cm in length and this student nurse changed the dressing to a non-
adherent pad with paper tape on 02/07/2011. Her IV site, located in her left forearm appeared
clear but upon saline flush, leaking was noting at the point of insertion. IV site was D/C and
changed by a nurse.
Upon auscultation, bilateral rales are heard that do not clear with cough. This finding is
consistent with the current diagnosis of pneumonia; which is an infection that occurs when fluid
and cells collect in the lung (Lewis, 2007). Her chest rises evenly bilaterally as she takes fast
shallow breaths. Her cough is productive as it produced thick yellow sputum. Her SpO2 is 94%
MAJOR CASE STUDY 4
on 1L oxygen via nasal cannula and respiratory rate is 24 indicating tachypnea. Patient
complained of Orthopnea and the head of the bed was elevated to accommodate.
Inspection of her abdomen revealed flat loose skin, and when questioned for areas of
tenderness she replied “no, none”. Auscultation revealed bowel sounds were positive in 4
quadrants and upon palpation, no rebound tenderness is noted, although the stomach appeared
large and swollen. Her nurse confirmed this was most likely a result of her recent surgery and I
continued to monitor its condition. She reported that she had had a soft small formed bowel
movement this morning and that she usually has one every day. Her oral mucosa was dry as a
result of a lubrication disorder. Her nutritional status is considered poor as her BMI is 18.2. She
consumed 40% of breakfast and 20% of lunch on this clinical day. Her ordered diet is consistent
carbohydrate which was ordered to help her control her diabetes. Her prescribed nutritional
supplement was placed with her lunch. She had a Foley placed upon admission which on this day
Apical pulse is 67 and the rhythm is regular as only s1 and s2 are noted. Radial pulse was
normal and equal bilaterally and pedal pulses were increased bilaterally. Blood pressure is
103/48 which is comparable to previously recorded data. Capillary refill was assessed on fingers
and toes both of which were greater than 3 seconds in return with no clubbing. Her fluid status
was evaluated and hydration was placed within her reach. Her range of motion is full and she
requires assistance needed for transfers and turning. She used a walker before admission. Gait
was unable to be assessed as full assistance was needed for any and all ambulation. She is weak
on the left side but manages to help when assisted to dangle legs from bed. Because of her
confusion and fall assessment score of 5 putting her at high risk for falls, a bed alarm was
attached. Additional safety measures were taken and included keeping belongings and call light
MAJOR CASE STUDY 5
within reach. She wears glasses, has upper and lower dentures, and did not require hearing aids.
When questioned for presence of pain, she reported yes, but her source was unclear. At one point
she complained of a tight chest, and dry mouth, and then later, complained of leg pain rating both
episodes at 8 on a 1 to 10 scale. The pain she reported was constant and not relieved by any
measure. She requested a “pain pill” (Percocet 5-325), which was given at 1200. Her response
after turning and propping up with pillows was a comfortable nap with no additional needs
voiced. The patient reports a very disturbed sleep as she states “I was up all night coughing”,
therefore the nap she attained following pain relief was therapeutic.
Medications
Home Medications
Reference Drug Average Indication Adverse Effects Drug Class d
Dose /
c
(Wilso Baclofen PO: 20-80 Spasticity CNS Depression Muscle Relaxant Y
10mg PO TID mg/day div Resp. Depression
n, Shannon, & tid-qid
Sheilds,
2010.p 150)
Q12h depression
None Miralax 17gm PO:Max:17 Constipation Electrolyte Osmotic Laxative N
Pack PO QD gm/d Imbalance, Laxative
dependence
None Theravite PO: 1 tab/d Health Iron Toxicity, Skin Vitamin and Y
Multavitamin Maintenance Flushing, Vitamin mineral
1Tab PO QD Toxicity combinations
“p 1135” Omeprazole PO:20mg/d Antiulcer/GE Headache, dizziness, Proton Pump N
DR 20mg Cap RD diarrhea, fatigue Inhibitor
PO QD Dyspepsia
None Oasis LIQD PO:2tbl Mineral Mineral Toxicity, Nutritional N
1-5 sprays PO spoons QD supplement Teeth deposits Supplement
QD PRN
None Refresh Tears 1-2 gtt in Dry Eye May occur but none Decongestants/Lu N
1.5% SOLN eye(s) prn reported bricants,
1-2 drops Ophthalmic
OPTH QD
PRN
None Systane 0.4% 1-2 gtt in Dry Eye May occur but none Decongestants/Lu N
SOLN 1-2 eye(s) prn reported bricants,
gtts OPTH Ophthalmic
QD PRN
* Physician lowered dose to 5/20mg PO QD and switched to generic formulation
Hospital Medications
Sheilds, 2010.
p 872.)
Q24h
“p 1589” Vancomyc IV: 1gm q12h Systemic Ototoxicity, Antibiotic;
in HCL Infection Nephrotoxicity, Glycopeptide
1000mg/N Shock-like State,
aCl 0.9% Red-Mans
250ml IV Syndrome,
[DR- Thrombophlebitis
125ml/h]
Q12h
None Miralax PO:Max:17gm Constipation Electrolyte Osmotic Laxative
17gm /d Imbalance,
Pack PO Laxative
QD dependence
PRN
Drug
“p 459” Robitussin PO:10-20mg Cough that Dizziness, Antitussive
DM 100- Q4h inhibits sleep drowsiness, CNS
10mg/5ml Depression
PO Q4-6h
PRN
“p 1669” Percocet PO: 5-10mg Mod-Severe Hepatotoxicity, Opiate
5-325 tab Q6h PRN Pain respiratory Agonist/Analgesic
PO Q4h depression,
PRN sedation
“p 1137” Zofran IVP:4-8mg N/V Headache, Antiemetic
4mg IVP Q6-8h sedation,
Q6h PRN
The patient is compliant with ordered medications. The patients overall polypharmacy
nausea, constipation, pain, dyspepsia, anxiety, a disorder in lubrication and effectively promotes
her health. The overall effectiveness of her polypharmacy is established via standardized tests,
lab results and positive patient verbalization. Problems indicated in the regimen are few and are
The physician discontinued Baclofen for her stay in the hospital most likely because of
the additive effects it could have caused her to have while taking Klonopin and Percocet.
MAJOR CASE STUDY 8
Klonopin, Percocet and Baclofen all have an adverse effect of respiratory depression and CNS
depression.
The effectiveness for Klonopin is minimal as on this clinical day, this student nurse
witnessed verbalizations from the patient that seem agitated indicating anoxolytic effects of the
drug were minimal. Lotrel is considered effective as the patient’s blood pressure is 103/48 using
considered effective as the patient did not exhibit any symptoms of hypo-, or hyperthyroidism.
Miralax is effective in this patient as she produced a small formed bowel movement on this
clinical day’s morning. Omeprazole is effective as an antidyspeptic agent as the patient did not
verbalize to the contrary. Refresh and Systane effectively controlled her disorder of lubrication in
her eyes as she did not verbalize to the contrary. Levaquin and Vancomycin were effective in
reducing symptoms of community acquired pneumonia, and pathogenic microbes in the patient
as leukocytes in the blood obtained for CBC were reduced from 26.5K/ul to 18.6K/ul in a matter
of 48 hours. Regarding Zofran and Robitussin, this student nurse did not witness any doses given
Treatments
discharge)
Pneumovax Injection As Needed An opportunity to become actively
immune to the current pneumonia
(generally offered at discharge)
Laboratory
Hematology
Chemistry
Urinalysis
Microbiology
Vancomycin Studies
Feature 02/06 1532 02/06 1135 02/02 1715 Range Reason Reference
CKMB 15.9units/l 0.0 – 10.4 Cancer, (Malarkey, & McMorrow,
Surgery 2005, p. 180)
Troponin 0.0pg/ml 0.0 – 0.2 (Malarkey, & McMorrow,
2005, p. 180)
BNATPEP 479.78pg/dl 0 – 100 CHF, (Malarkey, & McMorrow,
Acute 2005, p. 749)
MI
Vanco-PK 39.27ug/ml 30 - 40 (Malarkey, & McMorrow,
2005, p. 697)
Vanco-TR 17.66ug/ml 5 - 10 Impaire (Malarkey, & McMorrow,
d 2005, p. 697)
Excreti
on
Diagnostic Studies
Chest X-ray done in ER was positive for pneumonia in both lungs on 02/02/2011.
Pathophysiology
MAJOR CASE STUDY 13
transformation of cholangiocytes, the epithelial cells lining the biliary tree” (Gatto, & Alvaro,
2010). The incidence of this disease is rare in Western countries such North America where
there are approximately 2500 cases annually (Krokidis, Fanelli, Orgera, Bezzi, & Passariello,
2010). It is the second most common cancer in the hepatobiliary region but is considered rare
because it accounts for less than 2% of all human malignancies (Krokidis, Fanelli, Orgera, Bezzi,
& Passariello, 2010). The etiology associated with CCA is varied by country. China, Japan,
Korea, Vietnam, Thailand, Laos, and Cambodia have done studies attributing the malignancy to
Clonorchis sinensis, Opisthorchis viverrini, (two types of helmith organisms) and HBV or HCV
infections(Hai-Rim, Jin-Kyoung, Masuyer, Curado, & Bouvard, 2010). In America, the HBV
and HCV viruses were somewhat reduced with vaccinations in the early 1970’s (Hai-Rim, Jin-
Kyoung, Masuyer, Curado, & Bouvard, 2010). America attributes the prevalence of CCA to
cirrhosis, chronic non-alcoholic liver disease, primary scleosing cholangitis (PSC), obesity, and
hepatolithasis (Gatto, & Alvaro, 2010). These risk factors are not presented in patients 90% of
the time as most patients with CCA are asymptomatic (Hai-Rim, Jin-Kyoung, Masuyer, Curado,
& Bouvard, 2010). CCA was discovered in the US when iatrogenic exposure of Throtrast
(thorium dioxide), a radiocontrast agent used in the 1950’s and 1960’s led to reports of CCA in
the 1970’s (Gatto, & Alvaro, 2010). Another emerging theory explaining the etiology of the
disease is the presence of an abnormal biliary-pancreatic junction causing the pancreatic juice
and bile to mix forming lysolecithin (Gatto, & Alvaro, 2010). Lysolecithin then acts as a
detergent on the biliary epithelium which causes chronic inflammation to the bile duct and
eventually, malignancy is formed after the constant regeneration of tissue for an extended
MAJOR CASE STUDY 14
amount of time (Gatto, & Alvaro, 2010).. The abnormal junction was found in one study to be
The clinical manifestations of CCA in this patient are unknown as she was diagnosed
with the malignancy previously to this admission to the hospital, but generally most patients who
are not asymptomatic present with: abdominal pain, diminished appetite, weight loss, malaise,
night sweats, cholestasis, and (or) a palpable hepatic mass(Gatto, & Alvaro, 2010).
Unfortunately, treatment options are minimal as most patients are asymptomatic up until the final
stages of the disease. During these stages, treatment is palliative and includes the placement of a
shunt (either Viabil or uncovered wallstent) to keep the bile ducts patent (Krokidis, Fanelli,
Orgera, Bezzi, & Passariello, 2010). Viabil stent placement versus uncovered wallstent
placement improved the outlook of patients by increasing the length of survival from 180.5 days
(wallstent) to 243.5 days (Viabil) (Krokidis, Fanelli, Orgera, Bezzi, & Passariello, 2010). If
caught early enough, complete surgical resection of the tumor improves patient outlook although
>5% of operated patients will survive 5 years (Krokidis, Fanelli, Orgera, Bezzi, & Passariello,
2010). No study has been established to evaluate the survival rate of those with CCA who have
undergone liver transplant. Additionally, without surgical intervention, body wasting occurs and
Nursing Diagnosis
MAJOR CASE STUDY 15
According to Maslow’s hierarchy of needs, a patent airway is the highest priority in life
(Gulanick, & Myers, 2010. p 429). This being said, a diagnosis of ineffective airway clearance is
the highest priority to receive interventions in this selected patient. The patient presents with
rales in bilateral lung fields, constant coughing impairing the ability to sleep, and thick yellow
sputum. These characteristics of her pneumonia define the selected nursing diagnosis and require
this student nurses’ immediate attention when conducting assessments, monitoring the patient,
Expected outcome.
Patient will maintain clear open airways as evidenced by normal breath sounds, normal rate and
depth of respirations, and ability to effectively cough up secretions after treatments and deep
Nursing interventions.
Intervention #1
B.) This student nurse auscultated all lungs fields as part of the shift assessment and
Intervention #2
Instruct the patient on the importance of ambulation and frequent position changes (done)
A.) Ambulation helps maintain adequate lung expansion, mobilizes secretions, and
B.) This student nurse positioned the patient twice during the clinical day with pillows
C.) Patient not only tolerated the procedure well, but was able to settle into a nap after
Intervention #3
A.) These techniques facilitate clearance of secretions and prevent atelectasis. Dyspnea
Happ, 2009).
B.) Pillows used for positioning were also used as instructional models for teaching how
to cough more effectively by the use of splinting. Pursed-lip breathing was explained
and demonstrated to the patient but the patient refused a return demonstration.
C.) Aside from confusion of the mechanism of pursed-lip breathing, the patient tolerated
Intervention #4
A.) A variety of medications are available to treat specific problems. Most promote
clearance of airway secretions and may reduce airway resistance (Gulanick, & Myers,
2010. p 430).
MAJOR CASE STUDY 17
B.) This student nurse administered all medications due during the clinical day and
noticed easier breathing, less pain while coughing and the patient experienced no side
effects.
C.) Patient tolerated medication administration and absorption well with no side effects
or complaints.
Intervention #5
A.) Increasing the amount of desired fluids to the patient gives them more of a choice to
decide which fluid they should intake, thus increasing fluid intake overall and helping
B.) This student nurse assessed the patient for drink preference, then consulted dietary
who accommodated the request. The patient consumed 296ml of hot tea with honey
C.) The patient demonstrated a more relaxed affect and had a more productive cough that
resulted in less frequent coughing fits with greater sputum removal and an increased
Nursing Diagnosis
Impaired gas exchange related to altered oxygen supply secondary to community acquired
Airway may be the upmost priority but the ability for alveoli to exchange oxygen is
second in the requirements of respiration (Marieb, & Hoehn, 2008. p 729). Upon admission to
MAJOR CASE STUDY 18
the emergency department, the patient had oxygen saturation levels at 84%. Since then, x-ray
studies of the chest have concluded pneumonia which is altering the way her body exchanges
oxygen and co2 by filling the alveoli with fluid. Without interventions, this patient could decline
into a state of hypoxia resulting in irreversible brain and lung damage or worse, including death.
Expected outcome
Patient maintains optimal gas exchange as evidenced by SpO2 levels above 90%, alert
responsive mentation, relaxed breathing, and a baseline heart rate of 82 beats per minute by the
Nursing Interventions.
Intervention #1
Assess for tachycardia, restlessness, irritability, diaphoresis, headache, visual disturbances, and
confusion (done)
A.) These are early nonpulmonary signs of hypoxia; lethargy and somnolence are late signs.
B.) This student nurse witnessed varying amounts of confusion with the patient and during
these episodes attached a SpO2 monitor to the finger of the patient in order to better
assess her respiratory status. A correlation was then found between confusion, SpO2
C.) After reattaching the oxygen, the patient seemed less confused and more comfortable
Intervention #2
Teach the need to restrict and pace activities to decrease oxygen consumption during acute
episodes (done)
MAJOR CASE STUDY 19
A.) Energy conservation during episodes of respiratory distress reduces fatigue and Dyspnea
thus allowing more productive oxygenating breaths (Gulanick, & Myers, 2010. p 432).
B.) This student nurse did witness and acute exacerbation of respiratory distress and did
educate the patient on the risks associated with trying to walk while suffering from
hypoxia. The patient did not understand but submitted to remaining still while the nasal
C.) The patient during the teaching session suffered from confusion and did not reverbalize
why she needed to pace herself; But after correcting the hypoxia the patient did say she
needed to rest.
Intervention #3
Pace activities and schedule rest periods to prevent fatigue. Assist with activities of daily living
(Done)
A.) Activities will increase oxygen consumption and should be planned so the patient does
B.) This Student nurse managed to adequately pace activities by separating necessary nursing
care by 30 minutes for each activity. Activities paced include: Giving the patient a
shower, changing the gown of the patient, the shift assessment, changing the dressing of
the patients flank incision, and allowing visitors for company to the patient.
C.) The patient tolerated all activities well and SpO2 levels remained above 90% with the
Intervention #4
A.) Supplemental oxygen may be required to maintain PO2 at an acceptable level (Gulanick,
B.) This student nurse did reapply the patient’s nasal cannula delivering 1L of oxygen many
times throughout the clinical day with much success as the patient maintained well above
90% oxygen the entire clinical day excluding the shower where this student nurse
obtained permission to remove the patient from oxygen which resulted in a SpO2 level of
89%.
C.) The patient tolerated the repositions with minimal discomfort after Band-Aids were
Intervention #5
Assess the patient's ability to cough effectively to clear secretions. Note quantity, color, and
A.) Retained secretions impair gas exchange and changes in color depict changes in the status
B.) This student nurse did provide tissue at all times during the clinical day of her care. In
doing so, the patient did use the tissue to expectorate. While the patient slept, this student
nurse did don gloves and examined the tissues containing expectorated sputum. The
sputum at the beginning of the clinical day did contain dark yellow sputum with tan
streaks, and at the end of the clinical day did contain lighter color sputum without streaks.
The sputum assessment allowed for accurate further intervention in the action of
C.) The patient was unaware of the intention to examine the sputum but otherwise did not
Nursing Diagnosis
Imbalanced Nutrition: Less than body’s requirements related to increased metabolic needs
Adequate nutrition is required to meet the body’s demands (Dune 2008. p 1272).
necessary to keep up with the supply and demand (Dune, 2008. p 1272). Although nutritional
status is not as high of a priority as airway clearance or gas exchange, it is equally vital that the
patient maintain adequate nutrition to promote the return of the body to a homeostatic state of
wellness. This patient having a BMI of 18.2 puts her at an increased risk for an array of
malnutrition related deficiencies thus affecting the way the cells in her body do work. When the
work to be done is fighting off infection, malnutrition can allow the infection to linger by
inhibiting cellular metabolism and causing weakness in the patient thus affecting ambulation thus
Expected outcome.
Patient reverbalizes importance of nutrient dense foods, shows motivation for achieving
weight within 10% of optimal BMI, and shows improved strength when ambulating to dangle at
Nursing interventions.
Intervention #1
MAJOR CASE STUDY 22
Document actual weight and height, then inform patient of the findings to assess and invoke
A.) Patients may be unaware of their actual weight and height or weight loss due to
B.) This student nurse did weight the client but did not measure the height of the patient. This
student nurse then did inform the patient of her actual weight of 109lbs. The patient did
not seem surprised but rather seemed reminded of her current nutritional status.
C.) The patient experienced the emotional weight of her situation and verbalized an increased
Intervention #2
Monitor significant lab values suggestive of malnutrition such as serum albumin, red blood
A.) This test indicates degree of protein depletion (2.5 g/dL indicates severe depletion; 3.8 to
4.5 g/dL is normal) (Gulanick, & Myers, 2010. p 432). Anemia and leukopenia occur in
2008), indicating anemia and decreased resistance to infection (Malarkey, & McMorrow,
B.) This student nurse did note lab values associated with malnutrition and did note the
values of minerals contained in the ordered dietary supplement. Lab results were
suggestive of malnutrition (see laboratory). Dietary supplement values were adequate for
C.) Patient did tolerate venipuncture well as noted in patient care notes as this student nurse
Intervention #3
A.) Involving patients in their own nutritional care has been found to raise their intake of
B.) This student nurse did witness dietary ask the patient which meal items she would prefer
C.) The patient seemed to enjoy being included in the process of determining what she would
consume with each meal. It allowed her to make appropriate choices that were
Intervention #4
Teach patient how to select nutrient dense foods, what caloric intake would be adequate for her
A.) Patients may not understand what is involved in a balanced diet. They are better able to
ask questions and seek assistance when they know basic information (Dimaria-Ghalili, &
Peggi, 2008)
MAJOR CASE STUDY 24
B.) Success in this intervention would have been witnessed as a positive reverbalization of
teaching, and following the teaching; the accurate choosing of nutrient dense foods that
C.) The patient would presumably do very well as long as she had motivation for learning
Intervention #5
A.) Attention to the social aspects of eating is important in both the hospital and home
B.) This student nurse did sit at eye level while the patient ate and provided emotional
C.) The patient did prefer this student nurse and her niece to be present while eating and
Nursing diagnosis #1
Patient maintained clear open airways as evidenced by normal breath sounds, normal rate
and depth of respirations, and effectively coughed up secretions after treatments and deep breaths
Nursing diagnosis #2
Patient maintained optimal gas exchange as evidenced by SpO2 levels at 94%, alert
responsive mentation, relaxed breathing, and a baseline heart rate of 82 beats per minute by the
Nursing diagnosis #3
Patient showed motivation for achieving weight within 10% of optimal BMI, and showed
improved strength when she ambulated to dangle at bedside by the end of the clinical day on
The best possible outcome for this client would be for her to remain as comfortable as
possible during her disease process in the company of her family and friends. Additionally, her
dignity throughout her palliative care would remain intact and this all would be evidenced by her
discharge to family and (or) friends, where she would have positive verbalizations reflecting
This was this student nurse’s first experience with a terminal illness. Knowledge is
gaining in this student nurse in the areas of palliative care, bile duct malignancies, lab results and
alternative treatment options surrounding palliative care. Although the patient remained confused
regularly throughout the duration of the clinical days with this patient, the times when she was
not were interesting as she talked about her life and children. Situational levity remained
appropriate and was appreciated as it assisted with her coping mechanisms already in place.
MAJOR CASE STUDY 26
References
Balas, M.C., Casey, C.M., & Happ, M.B. (2009). Comprehensive assesment and management of
the critically ill. Informally published manuscript, New York University, New York,
http://consultgerirn.org/topics/critical_care/want_to_know_more
Dunne, A. (2008). Malnutrition and the older adult: care planning and management. (Cover
EBSCOhost.
Dimaria-Ghalili, R.A., & Peggi, P. A. (2008). How to try this: the mini nutritional assessment.
Gatto, M., & Alvaro, D. (2010). Cholangiocarcinoma: risk factors and clinical presentation.
Gulanick, M., & Myers, J. (2010). Nursing care plans: diagnoses, interventions, and outcomes.
Hai-Rim, S., Jin-Kyoung, O., Masuyer, E., Curado, M.P., & Bouvard, V. (2010). Epidiemology
585
MAJOR CASE STUDY 27
Krokidis, M., Fanelli, F., Orgera, G., Bezzi, M., & Passariello, R. (2010). Percutaneous treatment
Lewis RL. Liver and biliary tract tumors. In Goldman L, Ausiello D, eds. Cecil Medicine.
Malarkey, L. M., & McMorrow, M. E. (2005). Saunders nursing guide to laboratory and
Marieb, E. N., & Hoehn, K. (2008). Anatomy & physiology. San Francisco, CA: Benjamin
Cummings.
http:consultgerirn.org/topics/hydration_management/want_to_know_more
Wallace, M., & Shelkey, M. (2008). Why assess older adults’ ability to perform. American
Wilson, B.A., Shannon, M.T., & Sheilds, K. M. (2010). Pearson nurses's drug guide 2010. New