TARLAC STATE UNIVERSITYCOLLEGE OF NURSING

Lucinda CampusBrgy. Ungot, Tarlac City

A Case Study on Acute Pyelonephritis

In Partial Fulfillment of the Requirements of the SubjectNursing Care Management 102 RLE

Presented to the Faculty Of the Tarlac State University

College of Nursing

Presented by:BSN III - C Group C4

Querido, RichenRaiz, Jayscent

Rodriguez II, RolandoSabat, AprillynSantos, Marivic

Santos, Willa MilafrosaSotelo, Jeffrey

Suarez, Christine KarenSumang, Jerico

Sumaoang, Maria Luisa

Date Submitted:December 5, 2009

INTRODUCTION

One of the most common renal diseases, acute pyelonephritis (also known as acute infective tubulointerstitial nephritis) is a sudden inflammation caused by bacteria that primarily affects the interstitial area and the renal pelvis or, less often, the renal tubules. (Handbook of Diseases, 3rd

Edition by Springhouse)

Acute pyelonephritis is most common in adult females but can affect people of either sex and any age. Its onset is usually sudden, with symptoms that often are mistaken as the results of straining the lower back. Pyelonephritis often is complicated by systemic infection. Left untreated or unresolved, it can progress to a chronic condition that lasts for months or years, leading to scarring and possible loss of kidney function. Acute pyelonephritis results from bacterial infection of the kidneys. Infecting bacteria usually are normal intestinal and fecal flora that grow readily in urine. The most common causative organism is Escherichia coli, but Proteus, Pseudomonas, Staphylococcus aureus, and Streptococcus faecalis may also cause such infections. (Handbook of Diseases, 3rd Edition by Springhouse)

Typically, the infection spreads from the bladder to the ureters, then to the kidneys, as in vesicoureteral reflux. Vesicoureteral reflux may result from congenital weakness at the junction of the ureter and the bladder.  Bacteria refluxed to intrarenal tissues may create colonies of infection within 24 to 48 hours. Infection may also result from instrumentation (such as catheterization, cystoscopy, or urologic surgery), from a hematogenic infection (as in septicemia or endocarditis) or, possibly, from lymphatic infection. (Handbook of Diseases, 3rd Edition by Springhouse)

Pyelonephritis may also result from an inability to empty the bladder (for example, in patients with neurogenic bladder), urinary stasis, or urinary obstruction due to tumors, strictures, or benign prostatic hyperplasia. (Handbook of Diseases, 3rd Edition by Springhouse)

Approximately 250,000 cases of acute pyelonephritis occur each year, resulting in more than 100,000 hospitalizations.3 Women are approximately five times more likely than men to be hospitalized with this condition (11.7 versus 2.4 hospitalizations per 10,000 cases, respectively); however, women have a lower mortality rate than men (7.3 versus 16.5 deaths per 1,000 cases, respectively).4 Acute pyelonephritis occurs in 1 to 2 percent of pregnant women, increasing the risk for premature labor and low-birth-weight infants. (Diagnosis and Management of Acute Pyelonephritis in Adults, Kalyanakrishnan Ramakrishnan, M.D., and Dewey C. Scheid, M.D., M.P.H.)

OBJECTIVES OF THE CASE STUDY

NURSE-CENTERED

General:

This study is aim to gain or broaden the knowledge and skills with regards

to the disease condition acute cystitis.

Specific:

1. To gain more knowledge about acute cystitis, its epidemiology, contributing

factors, pathophysiology, clinical manifestations, and the treatment required

2. To enhance the student skills by performing various nursing interventions to solve

or alleviate the patient’s needs as implementations of the formulated plans of care

3. To promote the student’s wellness of social health by conducting a healthy social

interaction with the patient

4. The nurse should be able to impart knowledge to the patient and significant others

regarding the patient’s condition

5. To gain fulfillment during and after rendering care to the patient, thus uplifting

their emotional health

PATIENT-CENTERED

General:

To educate the client about her current condition and render nursing

interventions that will respond to her needs

Specific:

1. To increase the client’s knowledge about her disease, which is acute cystitis by

means of giving health teachings in the contributing factors, disease course,

manifestations and treatments involved

2. To address the patient’s needs and problems that accompany the disease by

performing appropriate nursing interventions based on health care plans

3. To promote her emotional well-being by encouraging her to speak of whatever

she feels about her disease condition

4. The client should be able to gain knowledge about her condition and the different ways on how to understand and accept her state of being.Reasons in choosing the Case Study

Our group chose this case study to gain knowledge about the disease. The group wants to know more about the disease, its treatment, and the proper nursing management for patients with this kind of disease. The case will help the group in dealing with patient with the same condition.

Our curiosity leads us to choosing the disease condition to study.

Promotion of health, prevention of diseases and illnesses, rehabilitation and restoration of good health are important in doing the case. In the accomplishment of case study, the group will be able to know and develop more fully our skills in assessment, planning, nursing care plans, implementation/interventions and evaluation.

Importance of the Study

The case study is important because it would further help us in dealing with patient with the same condition and of course be competitive enough to provide the nursing management entitled for the needs of our patient. It provides broader comprehension about the condition chosen through research and actual observation as it serves as training and practice in developing learned skills in the assessment and management of the said disease.

Through this case study, a holistic approach in assessing the patient’s health will be delivered where it can be immediately attended to and given proper interventions. It serves as a way to familiarize the students with the different medical approaches toward the ongoing curative phase.

This study serves as a tool for upcoming nursing students of the school. And this is also for other nursing colleagues for them to understand the dynamics of diabetes mellitus type II as to the book-based management and actual clinical interventions. Furthermore, this study may be used as a spring board for a more advanced and in depth study that is in accordance to changing and developing society.

NURSING PROCESS

Assessment

A. Demographic data

Name: Mrs. Clover

Sex: Female

Age: 51-years old

Civil Status: Married

Birth date: Sept. 15, 1958

Place of Birth: Tarlac city

Chief complaint: Dysuria and hematuria, with nausea and vomiting

Diagnosis: Acute Pyelonephritis

Nationality: Filipino

Role in the Family: Mother

Religion: Roman catholic

Health Care Financing: Philhealth

Usual Source of Medical Care: RHU/Gov. Hospital

B. Environmental Status

Mrs. Clover’s house is made up of cement and wood. It composes of two

bedrooms, small kitchen, one living room and one toilet room. She stated that

there is presence of threats that could cause injury to them. Their house is located

near the road and surrounded by near house. Trees were planted at their yard

according to the patient. They also have domestic animals like dogs in their

house. They get their water from a water pump near their house. Their toilet is

located at the back of their house

C. Lifestyle

Mrs. Clover is regularly doing the household chores and it serves as her

daily exercise. After doing all household chores, she spends her time chatting with

her neighbours and then goes to sleep during siesta time. Another past time

activity that she is fond of is watching television. She usually sleeps at around

9:00 pm and wakes up at around 6:00 am, but because of frequent urination she

has sleep deprivation.

D. History of past illness

Mrs. Clover suffers from UTI for one year. She experienced pain and

burning sensation during urination. She has no history of serious hospitalization

and injuries except when she gave birth to her last child two months ago. She

mentioned that she had chicken pox and some minor injuries in her school-age

years. She has no known allergies to food, medications, animals, dust, etc. Patient

also said that she received immunizations but she cannot remember what vaccines

she received. She usually feels headache and dizziness. Some medications she

took are paracetamol, and other OTC medicines for cough, colds and headache.

E. History of Present illness

A year prior to hospitalization, Mrs. Clover experienced difficulty

urinating and then consult doctor about what she experienced. The doctor told her

that she has urinary tract infection. During those times that she felt symptoms of

UTI like fever and chills, nausea and vomiting, back pain she just stay in her bed

and rest for a while.

Two days prior to consultation, condition persisted accompanied by

dizziness and excessive pain during urination, with foul smell. She also noticed

blood tinged when urinating.

An hour prior to consultation, Mrs. Clover suddenly felt flank pain

accompanied by body weakness and is unable to stand alone hence decided to

consult her doctor, she was rushed to Tarlac Provincial Hospital. She was given

IFV and undergone laboratory exam to rule out the disease she has.

13 Areas of Assessment November19,

2009

A. Social Status

Mrs. Clover is the one whose is responsible in managing their house. She

does the household chores and taking care of her children. According to her, she

had a good relationship with her family and relatives as well to her neighbors. She

lives together with her husband and two children. The family maintains a good

relationship with each other. According to her they express their love and concern

within the family by helping each other when they have their problem and doing

the household chores together.

NORMS:

The ability to interact successfully with people and within the environment

of which each person is a part, to develop and maintain intimacy with significant

others, and to develop respect and tolerance for those with different opinion and

beliefs. (Kozier B. 2004, Fundamentals of Nursing Concepts, Process and

Practice Seventh Edition p.172) Families consist of persons and their

responsibilities within the family. A family structure of parents and their offspring

is known as the nuclear family (Kozier B. 2004, Fundamentals of Nursing

Concepts, Process and Practice Seventh Edition p.191) The ability to achieve

balance between work and leisure time. A persons belief about education,

employment and home influence personal satisfaction and relationships with

others (Kozier B. 2004, Fundamentals of Nursing Concepts, Process and Practice

Seventh Edition p.173)

INTERPRETATION:

The client’s social status is in a well state as manifested by the client,

having no problems in interacting with other persons especially in her family. She

fulfills her part in the family and able to manage her time (doing the house hold

chores, watching television, etc.)

B. Mental status/Neurological Status

During the assessment, the patient is oriented to time, date and place. By

answering my question “nay anung oras nyu po iniinum ang gamut nyung

ceftriaxone?” she response “kada ikalabing dalawang oras”. She gave accurate

information and appropriate answers to the questions being asked. The patient

exhibits good communication by demonstrating good eye to eye contact.

NORMS:

Consciousness: Being aware of one’s own existence, feelings and thoughts and

aware of the environment.

Language: Using the voice to communicate one’s thoughts and feelings.

Attention: The power of concentration, the ability to focus on one specific thing

without being distracted.

Memory: The ability to lay down information and store experience.

(Carolyn Jarvis, Physical Examination & Health Assessment 3rd Edition)

INTERPRETATION:

The patient is not demonstrating any signs of alteration in her mental

status. She has normal cognition during the interview and able to answer

accurately to the questions being asked to her.

C. Emotional Status

During interview, Mrs. Clover shown poor eye contact with facial tension

and restless. On the other hand during the interview Mrs. Clover expressed

frustrations because she never thought that all the things that she have done were

all wrong that leads her in having her condition. She admitted that she had fear of

urinating with blood. But she manages to divert attention to other things.

NORMS:

A person expresses themselves as optimistic and a positive thinker in life.

There should no presence of fear, anxiety, grieving etc. The patient should have

the ability to manage stress and to express emotions appropriately. It also involves

the ability to recognize, accept, and express feelings and to accept one’s

imitations. (Kozier, B. (2004). Fundamentals of Nursing: Concepts, Processes

and Practice. Seventh edition)

INTERPRETATION:

The client is able to express her optimistic perception in life even with

some fear and anxiety.

Sensory Perception

Sense of Sight

Based on the assessment, Mrs. Clover has no alteration in sense of

sight. We provide a newspaper to test her sense of sight she read the headlines

correctly. Her eyes are symmetrical and round and sclera is white in colour.

NORMS

Eyes symmetrically aligned, equal movement, eye bilaterally blinking,

sclera appears white, skinny smooth conjunctiva no edema and tenderness on

lacrimal gland. Eyes glasses are use to correct refractive disorders.

Sense of Taste

Mrs. Clover does not have any alteration in her taste, she can able to

determine the foods taste as she mentioned that she can differentiate various taste

such as sour, bitter, sweet and others with the foods that she eats. Her tongue is

reddish and in normal position and can move freely.

NORMS:

Tongue is reddish/pink in color, central in position, no lesions, raised

papillae (taste buds), moves freely, no tenderness no palpable nodules.

Tactile Sensitivity

Upon examination, one of the group member pinched her right and left

arm and ask her to tell the sensation. The patient responded and verbalized what

she felt and stated that she felt pain when she was pinched. She complains with

flank pain with the pain scale of 7/10 during the interview.

NORMS:

The skin contains receptors for pain, touch, pressure and temperature.

Sensory signals that help determine precise locations on the skin are transmitted

along rapid sensory pathways, and less distinct signals such as pressure or poorly

localized touch are sent via slower or sensory pathways. (Health Assessment and

Physical Examination, Mary Ellen Zator Estes 5th Edition)

INTERPRETATION:

The patient’s sensory transmission functions are within the normal as manifested

by the data presented.

D. Motor Stability

Mrs. Clover is able to ambulate with assistance. She feels easy fatigability

and weakness during minimal movements.

NORMS:

Normal muscle strength allows for complete voluntary range of joint

motion against both gravity and moderate to full resistance. Muscle strength is

equal bilaterally. A healthy person can perform the different Range of Motion

(ROM). (Health Assessment and Physical Examination, Mary Ellen Zator Estes

5th Edition)

INTERPRETATION:

She has slight alteration in his motor stability because of easy fatigability

and weakness.

E. Body Temperature

Date and Time Results

November 19, 2009; 03:52 pm

38.3 0C via axilla

November 20, 2009; 04:30 pm

38.0 0C via axilla

November 21, 2009; 03:45 pm

37.80C via axilla

NORMS:

The normal body temperature ranges from 36.5 to 37.5oC (Fundamentals

of nursing Kozier 2004, 7th edition)

INTERPRETATION:

Based on the given norms the patient’s body temperature has alteration

due to infection caused by her present condition

G. Respiratory Status

Date and Time Results

November19, 2009; 03:52 pm

19 cpm

No retraction

November20, 2009; 05:30 pm

17 cpm

No retraction

November21, 2009; 05:45 pm

16 cpm

No retraction

NORMS:

There should be an absence of retractions and bulging of the (Inter Coastal

Spaces) ICS. In the resting adult, the normal respiratory rate is 12 to 20 breaths

per minute.

INTERPRETATION:

Upon assessment Mrs. Clover showed normal respiratory status.

H. Circulatory Status

On assessment the patient exhibit good capillary refill after the Blanch

Test by applying gentle pressure at the nail beds it return at 2 seconds. She had a

blood pressure reading of 130/90 mmHg and pulse rate of 84bpm. (November19,

2009; 03:52 pm)

Date and Time Result

November19, 2009; 03:52 pm

120/90mmHg

November20, 2009; 05:30 pm

130/80mmHg

November21, 2009; 05:45 pm

130/90mmHg

Pulse rate

Date and Time Result

November19, 2009; 03:52 pm

84bpm

November20, 2009; 05:30 pm

89bpm

November21, 2009; 05:45 pm

95bpm

NORMS:

Blanch test should return at 1 to 2 seconds and Normal blood pressure is

120/80 mmHg and the pulse rate is 60-100 bpm in adults. (Kozier, 2006)

INTERPRETATION:

Based on the data shown Mrs. clover blanch test is normal but her bp is

slightly elevated because of her present condition

I. Nutritional Status

During our assessment Mrs. clover is thin in appearance her weight is

42kg(92 lbs)and her height is 5 feet. Her nutritional status she suffering from

nutritional imbalance she eats 2-3 times a day. She usually takes 5-7 glasses of

water daily. She usually eats vegetables and salty foods like junk foods and plenty

of softdrinks.

Computation

Form

ula of

BMI

EQUATI

ON

RESULT

BMI=WEIGHT IN

KG

HEIGHT IN M

BMI=42k

g

2.322

6=18.08

UNDERWEI

GHT

NORMS:

Normal eating pattern is on the minimum of 3 – 5 times per day,

depending upon metabolic need and demands. Fluid is on the average of 8-10

glasses (2-3 liters) per day.

Body Mass Index Interpretation (Javis, 2000)

<18.5 ------------------------------ underweight

18.5 – 24.9 ----------------------- healthy

25.0 – 29.9 ----------------------- overweight

30> -------------------------------- obese

Food pyramid

(SOURCE: Physical Assessment and Health Examination 4th Edition,

Carolyn Jarvis)

INTERPRETATION:

Her BMI was interpreted as underweight (18.08). There is a problem in

her eating habits and her fluid intake was in below normal.

J. Elimination Status

Upon assessment, the urine output of Mrs. Clover was in 38 ml around 2

hours. Slightly red in appearance and with pain during urination. Usually had a

bowel movement of 1-2 times per day. Patient experienced frequent urination but

in small amount.

NORMS:

Normal bowel movement is 1-3 times per day and voids at 1,200 – 1,500

mL per day or 30-60 ml the normal color of stool is brown and well formed the

urine is clear and yellowish in color”(health assessment and physical

examination,3rd edition by Mary Ellen zastor estes).

INTERPRETATION:

The client experience hematuria due to her condition. This is because of

the inflammation of her kidney.

K. Rest and Sleep

Mrs. Clover stated that she only sleeps at 9:00 PM and wakes up at 6:00

AM. She usually sleeps 6-7 hours at night but has a disturbed sleeping pattern due

to her present condition. And she usually has afternoon naps of about 15 minutes

to an hour.

NORMS:

Older adults sleep about 6-8 hours of sleep at night (Kozier, 2004)

INTERPRETATION:

The patient sleeps inadequately due to her disturbed sleeping patterns. She

is not able to complete the normal sleep hours.

L. Reproductive Status

Mrs.clover had her first menarche when she was 16 years old her cycle

usually last for 5 days she experiences headache and pain on the pelvic area

during her cycle she usually use 2 pads with fully soak blood The patient had 2

children, a boy and a girl, which were delivered normally.

Standard menarche which is the first menstruation occur at an average age of

onset between 9 to 17 years old (maternal and child health nursing 4 th edition by

pilliterri)

INTERPRETATION:

The patient had a normal reproductive system since she had her menarche

at the right age

M. State of Skin Appendages

Generalized color; Mrs. Clover had fair complexion

Texture; there is no redness noted on the skin of Mrs. Clover

Moisture; the skin is dry perspiration was absent to her

Temperature; the patient skin was warm and dry.

.

NORMS:

Normally, the skin is a uniform whitish pink or brown color, depending on

the patient’s race. There are no areas of increased vascularity, ecchymosis, or

bleeding. No skin lesions should be present except for freckles, birth marks or

moles, which may be flat or elevated. The skin is dry with a slight perspiration

present on the hands, axilla, face and in between the skin folds. Skin should

normally feel smooth, even and firm except when there is significant hair growth.

A certain amount of roughness can be normal, hair varies from dark black to pale

blonde based on the amount of melanin present in light-skinned individuals and

light brown in dark-skinned individuals. The nail surface should be smooth and

slightly rounded and flat.

INTERPRETATION:

Mrs. Clover skin and appendages status was not affected there is no presence of

redness on her skin is warm to touch

ANATOMY AND PHYSIOLOGY

EXTERNAL ANATOMY KIDNEY

They are paired that are reddish in color and resemble beans in shape. They are

about size of a close fist located at retro peritoneally ( behind and outside

peritoneal cavity) on the posterior wall of the abdomen from 12 thoracic vertebrae

to the third lumbar vertebrae in adult. The average adult kidney weighs

approximately 133-170g. (4.5 oz) and is 10-12 cm long 6 cm wide and 2.5 cm

thick the right kidney is slight lower than the left due to the location of the liver.

Kidney are well protected by the ribs and by the muscles of the abdomen and

back3 LAYERS OF TISSUE SURROUNDING EACH KIDNEY

1.

RENAL CAPSULE

- innermost layer, it is a smooth transparent fibrous connective tissue membrane

that connects with the outermost covering of the ureter at the hilum. It serves as a

barrier against infection and trauma to the kidney

2.

ADIPOSE CAPSULE-

second layer it is a mass of fatty tissue that protects the kidney from blows. It

firmly holds the kidney in the abdominal activity

3.

RENAL CAPSULE-

outer most layer which consist of a thin of a layer of fibrous connective tissue

that also anchors the kidney to their surrounding structures and to the abdominal

wall

INTERNAL ANATOMY OF KIDNEY

The renal parenchyma is divided into two parts the cortex and the medulla

MEDULLA Medulla is approximately 5 cm wide which is the inner portion of the

kidney. It contains the loop of Henle, the Vasa Recta and the collecting ducts of

the juxtamedullary nephrons the collecting duct from both the juxtamedullary

and the cortical nephrons connect to renal pyramids which are triangular and are

situated with base facins the concave surface of the kidney and the point

(papilla)facins the hilum/pelvis. Each kidney contains approximately 8-18

pyramids. The pyramids drain into 4 to 13 minor calices which drain into 2 major

calices that open directly into the renal pelvis. The renal pelvis is the beginning of

the collecting system and is composed of structures that are designed to collect

and transport urine. Once the urine leaves The renal pelvis, the composition of

urine does not change.

CORTEX- It is approximately 2 cm wide, is located farthest from the center of

the kidney and around the outer most edges. It contains the nephrons.

NEPHRONS-these are the functional units of kidney. It is microscopic renal

tubule which functions as a filter. Each kidney has 1 million nephrons, which

usually allows for adequate renal function even if the opposite kidney is damaged

or becomes nonfunctional. The structures are located within the renal

parenchymas that are responsible for initial formation of urine.

2 KINDS OF NEPHRONS

a. Cortical nephrons – this makes up 80 to 85 % of total number of nephrons in

the kidney which are located in the innermost part of the cortex.

b. Juxtamendullary – nephrons which make up the remaining 15 to 20 % are

located deeper in the cortex. There are distinguished by long loops of Henle,

which are surrounded by long capillary loops called Vasa Recta that dip into

Medulla of the Kidney.

Nephrons are made up of two basic components; a filtering element component

of an enclosed capillary network and the attach tubule. The glumerulus is a unique

network of capillaries suspended between the afferent and efferent blood vessels,

which are enclosed in an epithelial structure called Bowman’s capsule. The

glumerular membrane is composed of three filtering layers: (a) Capillary

endothelium, (b) basement membrane, and (c) epithelium. This membrane

normally allows filtration of fluid and small molecules yet limits passage of larger

molecules, such as blood cells and albumin. The tubular component of the

nephrons begins in the Bowman’s capsule. The filtrate created in the Bowman’s

capsule travel first into the proximal tubule, then into loops of Henle, distal

tubule, and either the cortical or medullary collecting ducts. The structural

arrangement of the tubule allows the distal tubule to lie in close proximity to

where the afferent and efferent arteriole respectively enter and leave the

glumerulus. The distal tubular cells located in this area, known as the Macula

Densa which functions with the adjacent afferent arteriole and create what is

known as juxtaglumerulus apparatus. This is the site of the renin production.

Renin is a hormone directly involved in the control of arterial blood pressure; it is

essential for proper functioning of the glumerulus. The tubular component

consists of the Bowman’s capsule, the proximal tubule, the descending and

ascending limbs of the loop of Henle, and the cortical and medullary collecting

ducts. This portion of the nephrons is responsible in making adjustments in the

filtrate based on the body’s needs. Changes are continually made as the filtrate

travels through the tubules until it enters the collecting system and is expended

from the body.BLOOD SUPPLY TO THE KIDNEYThe hilum of pelvis is the

concave portion of the kidney through which are renal artery enters and ureters

and renal vein exit. The kidney received 20% to 25% of the total cardiac output,

which means that all of the body’s blood circulates through the kidneys

approximately 12 times per hour. The renal artery (arising from the abdominal

aorta) divided into smaller and smaller vessels, eventually forming the afferent

arterioles. Each afferent arterioles branch to form a glumerulus, which is the

capillary bed responsible for glumerular filtration.

CONCLUSION

Having series of research about acute pyelonephritis, its management and after

completing the case study, the group had come out with the following conclusion:

Patient’s condition was enough proven by adequate data gathered

Proper analysis was made so that nursing problems were formulated.

Evaluated patient’s health situation through Community Duty by Home health

teaching like nursing interventions about diet, drugs.

RECOMMENDATION

Having studied the condition of the patient, we come up with the following

recommendation:

Medication:

- Continue medications as prescribed- Prescribed medication must be taken on time

Exercise:

- Strenuous exercise should be avoided- Encouraged to take enough rest to regain strength

Treatment:

- Take home medications as doctors’ order- Report unusual signs and symptoms

Health Teachings:

- Advised the client to have enough bed rest- Upon discharge patient education should emphasize the importance of close

follow up care - Encourage to practice personal hygiene properly- Void when there are urged to urinate- Wipe from back to front to prevent bacteria around the anus from entering the

vagina or urethraDiet:

- Diet as tolerated - Increase fluid intake - Advised the patient to eat vegetables, fruits rich in vitamin C and fiber rich foods.

VI. Bibliography

NANDA International.(2003). NANDA nursing diagnosis: Definitions and Classification

2003-2004.Philadelphia: Author

Rizzo,D.C.,(2006).Fundamentals of Anatomy and Physiology(2nd ed.)

Claudio,U.S.,et.al.(2004)Basic Nutrition for Filipinos(fifth edition)

Mosby,E.,(2006).Pocket Dictionary of Medicine, Nursing and Health Profesions(fifth

Edition)