Nursing Process: Caring for a Patient with Cancer By: Maureen Metz, Kate Arnold & Caitlin McCallum

Assessment (Complications):  (Cummings-Winfield & Olson, 2010, p. 403).

Infection - Leading cause of death in cancer patients. Important to look for signs of infection (inflammation & fever), and monitor for sepsis. Common sites of infection in cancer patients include: pharynx, skin, perianal area, urinary tract, and respiratory tract. Cancer patients can have decreased circulating WBC so it becomes imperative to watch for Neutropenia (low absolute neutrophil count (ANC)). An ANC less than 1.0 x 109 equals a severe risk for infection.

Bleeding – Imperative to understand factors that contribute to bleeding such as: radiation, chemotherapy, and medications that interfere with coagulation/platelet functioning. Common bleeding sites include: skin/mucous membranes, intestinal, urinary and respiratory tracts, and brain. Nurses should be continually monitor for hemorrhage, and blood in stool, urine, sputum, vomit, oozing at injection sites, bruising, petechiae, and changes in mental status

Skin problems - Very important to continually assess the patient's skin. Risk factors for potential loss of skin integrity include: nutritional deficits, bowel and bladder incontinence, immobility, immunosuppression and multiple skin folds.

Hair loss & Body Image - Must assess patient’s ability to cope with assaults to body image and depersonalization due to treatments and hospital stay. It’s important to understand the patient is facing realization of illness, disfigurement, possible disability, and death.

Nutritional concerns - Often weight and caloric intake must be monitored on a consistent basis. It’s important to gather health history including past episodes of anorexia, changes in appetite, and foods that may aggravate or relieve anorexia. Assess any difficulty chewing or swallowing and nausea. Keep an eye on lab data (electrolytes, protein, lymphocyte, and hemoglobin levels) and note any vomiting or diarrhea.

Pain - Physical and psychological needs must be evaluated, including: fear, apprehension, fatigue, anger, social isolation. Be sure to use objective tools (pain scale).

Fatigue - Asses for feelings of weariness, weakness, lack of energy, inability to carry out daily functions, lack of motivation, and inability to concentrate. Check appearance often (pale, with relaxed facial musculature). Be aware of physiologic and psychological stress factors that contribute to fatigue.

Psychosocial status - After diagnostic testing and prognosis be sure to assess mood and emotional reactions. Be mindful and watch for “evidence the patient is progressing through the stages of grief and can talk about diagnosis and prognosis with family” (Cummings-Winfield & Olson, 2010, p. 403).

Nursing Diagnosis: ( relevant to the situation)

Imbalanced nutrition , Anorexia , Cachexia , Chronic pain , Fatigue & Anticipatory grief

Interventions:

Managing Stomatitis (Day, 2010, p. 407)

o Bleeding, ulcers, redness of oral tissueso Can develop 5-14 days after receiving chemotherapeutic agents (In 40% of

patients)o Treat/Prevent with:

Good oral hygiene – floss, brushing and rinsing Soft brushes and non abrasive toothbrushes to prevent trauma to oral

mucosa Avoid alcohol based mouthwash (irritates oral tissue) Avoid foods that are difficult to chew or are spicy to prevent trauma Encourage adequate fluid and food intake is encourage May be prescribed topical anti-inflammatory or antibiotics to promote

healing (Pg. 406 +407)

Maintaining tissue integrity (Day, 2010, p. 407)o Patient receiving radiation therapy can have skin and tissue reactiono Need to prevent further skin irritation. drying and damage:

Avoid wearing clothes that irritate the affected area Blisters occur to not disrupt since it can introduce more bacteria Use moisture-and vapor permeable dressings (Eg. Hydrocolloidsm

hydrogels) Encourages healing

Practice aseptic wound care minimize risk of infection and sepsis May be prescribed topical Antibiotics

Helping Patients Cope with Alopecia (Day, 2010, p. 407)o Adverse side effect of radiotherapy and chemotherapy is permanent thinning or

complete loss of hairo Patients view hair loss as major attack on the body

Can cause anxiety, depression, anger, rejection and isolationo Nurse’s Role

Support patient in family in coping with this side effect on therapy (hair loss and altered body image)

Refer patients to support groups (Canadian Cancer Society) Encourage use of colorful scarfs and hats or wigs that match natural hair Inform patient regrowth occurs 8 weeks after last cancer treatment

Managing Malignant Lesions (Day, 2010, p. 408)o These type of lesions can cause significant amount of paino Carefully assess and cleanse the wound, control bleeding, decrease odor, decrease

any superficial bacteria, protect skin from further trauma or pain. Promoting Nutrition (Day, 2010, p. 408)

o Common Nutritional problems: Anorexia

Alteration in taste (Increased salty, sour and metallic taste, altered response to sweet and bitter)

Feel full after eating a small meal due to decrease in digestive enzymes, abnormalities in metabolism of glucose and triglycerides

Malabsorption

Due to tumor activity and cancer treatmento Impair enzyme production or produce fistulaso Secrete hormone and enzymes that irritate GI, cause peptic

ulcer disease, and decrease fat digestion Cachexia

Loss of body weight (adipose and muscle)o Inadequate nutritional intake, increase in metabolic

demands, impaired glucose metabolism, competition of nutrients with tumor cell, alerted lipid metabolism, suppressed appetite

o General Nutrition Considerations Avoid horrible smelling food Include family members in plan to encourage adequate nutrient intake Include patient preferences with the physiological and metabolic

requirements needed when selecting food Tend to tolerate larger meals earlier in the day Manage symptoms that interfere with nutrition (pain, nausea, vomiting) If not able to maintain adequate nutrition:

Other routes other than oral may be needed (ex. Enteral route)o Nasogastric tube, Gastrostomy or jejunostomy tube

Enzyme and vitamin replacement therapyo If more severe malabsorption = parenteral nutrition (PN)o Nurse teach family how to care for patient receiving PN

Nurse prevent trauma or infection that would increase metabolic demands Relieving Pain (Day, 2010, p. 409)

o 80% cancer patients experience paino Pain management will be discussed by Group 4

Addressing Fatigue (Day, 2010, p. 410)o Fatigue is most common symptom experienced with cancer therapy

Causes of fatigue: (Day, 2010, p. 410)

o Nurse educate patient that fatigue is expected and is temporary with cancer treatment

Nurse’s Role: Help patient identify source of fatigue

o Select individual intervention that works for them How patient can conserve energy during the day with planned

activitieso Prioritize necessary and valued activities

Alternate rest and activity periods throughout the day Regular light exercise – can decrease fatigue and help with coping Continue to do activities that patient enjoys and values Address/manage pain to decrease fatigue

Improving Body image and Self-Esteem (Day, 2010, p. 410)o Encourage patient to be active participant in care with decision making (increases

self-esteem)o Negative thoughts and feelings patient has about self-image should be addressed

and not ignored Nurse needs to use active listening skills

o Referral to support groups help coping with changes from cancer treatment Assisting in grieving process (Day, 2010, p. 411)

o Important for nurse to be there for patient to answer any questions and clarify information the doctor has told them

o Nurse identifies resources and support groups (pastoral care, counselor, etc.)o As patient progresses through cancer treatment, nurse encourages patient to

verbalize their emotions and feelingso Through final stages of cancer, nurse assist patient and family in coping with their

feelings Helps family and patient decide end-of life care (withdrawal of active

disease treatment, symptom management, life support) Monitoring and Managing Complications (Day, 2010, p. 412)

o Infection Assess for signs of infection especially fever (>38.3 Degrees Celsius) Treat with broad spectrum Antibiotics Use aseptic technique Avoid crowds of people Teach patient signs and symptoms of infection, proper hand hygiene, how

to maintain skin integrity, proper use of antipyreticso Septic Shock

Monitor for signs of septic shock and teach patient these signs(fever, altered mental status, cool clammy skin, decrease urine output, hypotension, dysrhythmia, electrolyte imbalance, altered arterial blood gases)

Nurse administer IV therapy, oxygen therapy, broad spectrum antibiotics, vasopressors

o Bleeding and Hemorrhaging Monitor for signs of Thrombocytopenia (decrease circulating platelet

count) Most common in cancer patients

Results from bone marrow depression due to chemotherapy and radiation therapy

Nurse prevents trauma to minimize risk of bleeding Softs foods and encourage fluid intake Make a safe home environment (no tripping hazards) Encourage to use soft bristle toothbrush

Patient Education (Day, 2010, p. 413-414)o Teaching patient self-care

Patient and family now responsible for care at home Review side effects of treatment and how to manage these side effects

o Continuing care Referral to home care

Assess home environment – suggest modifications if needed Assess changes in patient status and report to physician if

necessary Assess pain management

Cancer Rehabilitation

Begins early in cancer treatment to maximize beneficial outcomes Incorporates many inter-professional relationships with dieticians, physicians,

pharmacists (etc…) to get the patient through the transition Nurses play a huge part in helping patients resume pre-existing roles through

interventions with the patient, family and workplace Assessment of Cancer Patient’s Needs Include

o Functional Mobility Cognitive impairment Communication barriers

o Physiologic Nutrition Elimination function Symptoms related to disease

o Psychosocial Family (caregiver, home environment) Community (assistance and support) Personal (spiritual, relationships, body image, coping) Financial (job security, return to work)

Care of the Patient with Advanced Cancer

There are a wide range of symptoms that advanced cancer patients can experience such as gastrointestinal disturbances, nutritional problems, weight loss, cachexia, fluid/electrolyte problems, skin breakdown and infection

Weakness, immobility and fatigue generally occur as a result at end stage as a result of the accumulation of all other symptoms

o Important to set realistic goals and plan activities

o Appearance of new symptoms are always treated aggressively to ensure patient comfort

Primary issues is pain control, although not all experience ito Use of analgesia in set intervals rather than PRN, increases the patient’s comfort

and sense of controlo Opioid analgesics are used more commonly than any other medication

Very important to provide patient with as much control and independence with support and assistance as needed while respecting wishes of patient/family

Oncologic Emergencies

Superior Vena Cava Syndromeo Compression of superior vena cava by tumour/enlarged lymph nodes obstructing

venous circulation/drainage of the head, neck, arms and thorax – associated with lung cancer

o If untreated can result in cerebral anoxia, bronchial obstruction and death Spinal Cord Compression

o Compression of spinal cord from a tumour leading to permanent neurologic impairment, prognosis dependent on the severity/rapidity of onset, commonly caused by metastatic cancers and bone erosion

Hypercalcemiao Metabolic abnormality caused when Ca+ is released by the bones at a rate faster

than the kidneys can excrete resulting from bone destruction, prostaglandin production, tumours that secrete hormones and excessive use of vitamins and minerals

Pericardial Effusion and Cardiac Temponadeo Accumulation of fluid in the cardiac space, compressing the heart – impeding the

filling of the heart causing cardiac and circulatory failure, generally caused by tumours in thorax (lung, esophagus, breast)

o Large amount of fluid accumulate before symptoms are notices causing an apparent rapid onset

Disseminated Intravascular Coagulationo Disroger of coagulation causing thrombi’s or bleeding causing risk of impaired

circulation, tissue hypoxia and necrosis, most commonly associated with hematologic cancers, prostate, GI and lung cancer

Syndrome of Inappropriate Secretion of ADHo Continuous, uncontrolled release of ADH from tumour cells leading to increased

ECF, water intoxication, hypernatremia and increased excretion of urinary Na, commonly caused by small cell lung cancer

Tumour Lysis Syndromeo Complication associated with radiation/chemotherapy induced cell destruction or

rapidly growing cancers leading to release of intracellular contents causing electrolyte imbalances

References

Cummings-Winfield, C., & Olson, K. (2010). Oncology: Nursing Management in Cancer Care. In R. A. Day, P. Paul, B. Williams, S. C. Smeltzer, & B. G. Bare (Eds), Brunner & Suddarth’s textbook of Canadian medical-surgical nursing (6th ed.) (pp. 1661-1667). Philadelphia, PA: Lippincott Williams & Wilkins.

End of Life CareBy: Emily Yung, Aida Berhane & Sonam Grewal

Perspectives on End of Life Care (Olson, Ross, Hycha & Cummings-Winfield, 2010):

Historical Compared to the past, chronic and degenerative diseases are more common causes of death than communicable diseases

Technologic As technology advances, life can be prolonged and death is the perceived outcome of failed medical treatment

Legal Advance care planning includes written directives or instructions given by an individual that informs care givers of treatment and care wishes in the event he/she becomes incapable of making an informed decision

Sociocultural Each individual experiences illness in a unique way that is based on social and culture contexts

Clinician’s Approach to Death (Olson et al., 2010): Clinicians may be reluctant to discuss death with patients due to their own anxiety and misconceptions. A patient’s awareness of his/her health status can be categorized (awareness context) as follow:

Closed awareness: patient is unaware of own status but others are aware Suspected awareness : patient suspects information is being withheld and makes an effort

to find out Mutual pretence awareness : all parties pretend that the patient is not dying despite

knowing the opposite Open awareness: all parties are aware and acknowledge that the patient is dying

Patient and Family’s Approach to Death (Olson et al., 2010): Some individuals who are dying may be in denial to protect relationships and themselves due to their fear of being abandoned. Others may be accepting of their diagnosis and prognosis but may have misconceptions about their illness due to miscommunication with health care providers regarding end of life care and treatment.

Kübler-Ross’s Five Stages of Dying/Grief:1. Denial – adaptive or defensive response2. Anger – isolation, need to express anger3. Bargaining – need to maintain positive hope 4. Depression – adaptive response, need to avoid unrealistic hopes and insincere reassurance5. Acceptance – withdrawal and diminished interest in family or activities

Palliative Care (Olson et al., 2010): Strives to improve quality of life for patients and families faced with life-threatening illness. The principles of palliative care include:

Relief from pain and suffering Affirmation that dying is a normal life process Death is not rushed or delayed Patients live as actively as able until death Family supports available for coping & bereavement Team approach to care Care is relevant to early course of illness and can be used in with other therapies like

chemotherapy and radiation therapy

End of Life Care (End of Life Care Network, 2011): Total care of a person with an incurable, progressive and advanced illness. End of life is not the equivalent to dying as it can last weeks, months or years.

The Canadian Hospice Palliative Care Association Standards for end of life care are outlined below (Olson et al., 2010):

Open, honest and timely communication with patient Maintenance of patient comfort Ensure social support for caregivers Apply principles of palliative care Provision of individualized care from ethical, spiritual and cultural contexts

Hospice Care (Olson et al., 2010): Care that is delivered in a facility environment or home when patient is approaching end of life (approximately 6 months to live). Principles of hospice care include:

Death is accepted Interdisciplinary care is crucial Pain and symptom management is priority Patient and family is viewed as one unit in care Bereavement support must be given to family Education and research play an important role

Considerations in Advanced IllnessNursing Interventions

Pain Administer pain meds, do not delay or deny medicationsDyspnea Elevate head of bed, administer supplemental oxygen and airway

suction, bronchodilators, corticosteroids, low dose opioids Anorexia, Dehydration, Nausea, Cachexia

Maintain regular oral care, encourage fluid & ice chips, do not force feed patient, lubricate lips and oral membranes, administer anti-emetics before meals, offer small portions of favourite foods, schedule meals with family members to provide comfort and stimulation, allow patient to refuse foods and fluids

Delirium Identify underlying causes, spiritual intervention, gentle massage, therapeutic touch, music, reducing environmental stimuli, avoid harsh or dim lighting

Depression Relief of physical symptoms, attention to physical and spiritual

distress, pharmacological intervention Managing symptoms (Olson et al., 2010 & Silvestri, 2014):

Psychosocial support (Olson et al., 2010): The nurse’s role is to understand patient’s perspective and engage in open discussion about end of life issues in a safe environment

Communication (Olson et al., 2010): When communicating with a patient avoid medical jargon to explain diagnosis and care Ensure communication occurs at the patient’s convenience Be fully present and use active listening When delivering bad news, use effective and therapeutic communication such as:

o Avoid filling empty silence o Allow time for patient and family to reflect and respond to questionso Avoid distractions and giving adviceo Be empathetico Ask open ended questionso Assess understanding by rephrasing and summarizing

Culturally competent care (Olson et al., 2010): As nurses, it is important to reflect on our own experience and values related to illness

and death. Discussions with colleagues and others of different cultural backgrounds can assists nurses in viewing their beliefs through a different lens

Nurses should assess patient’s values and preferences such as desired location of dying, preparation for death and after death rituals

o Western cultures tend to value autonomy, honesty, and with-holding or with-drawing life support, but these may not be congruent with the patient’s values

Assess family specific preferences and beliefs regarding decision making and rituals

Goal setting (Olson et al., 2010): There has been a shift towards comfort care from disease focused treatment Priority goals should focus on symptom relief and quality of life May need to weigh the risks versus benefits of discontinuing treatment and diagnostic

testing Goals may include attaining psychosocial support as well as care and financial assistance

for the patient and family

Spiritual care (Olson et al., 2010): Spirituality centers around the individual’s meaning given to life Spirituality and religion not interchangeable but religion may be an aspect of spirituality Spiritual assessment is important

o The nurse needs to explore personal meaning of illness, relationship with others, patient’s purpose in life, religious/spiritual practices, meaning of hope, and the need to reconcile, forgive or accept circumstance

Universal components of hope (Olson et al., 2010): Realistic threat assessment

Setting goals and identifying alternative care Preparing for negative outcomes Determination of resources Identifying mutually supportive relationships Evaluation of outcomes and goal achievement Determination

To enable and support patient’s hope, nurses can:o Listen and reinforce positive memories and accomplishmentso Focus on patient strengthso Encourage realistic goalso Make referral for psychological and spiritual counselling

The Nurse’s Role in Active Dying - (death is imminent within days or hours)

Maintain patient comfort (Olson et al., 2010): administer medications, turning, mouth care, eye care, draining of secretions, skin care, and discontinuation of invasive/uncomfortable procedures such as lab work

Palliative sedation: used to minimize symptoms associated with dying such as dyspnea and seizures but does not accelerate death

Educate families of the signs of approaching death (Olson et al., 2010): Less interest in eating and drinking Decreased urinary output and frequency Patient is sleepy and detaches from environment Mental confusion and restlessness (less oxygen to supply the brain) Vision, hearing, speech impairments Rattle or gurgling (throat secretions) Irregular breathing (apnea) Inability to control body temperature Loss of bowel & bladder control Visualizing deceased loved ones and tranquil places

Provide reassurance and support during periods of grief, mourning and bereavement (Olson et al., 2010):

Grief: personal feelings accompanying loss Mourning: expression of grief and associated behaviours

o Grief and mourning can be anticipatory (throughout the illness), after death and complicated (prolonged grief and mourning)

Bereavement: period of time for mourning

Complete post-mortem procedures (Silvestri, 2014): Close the patient’s eyes Replace dentures Wash the body Place pads under the perineum Remove tubes and dressings

Prepare body for family viewing

Seek support to cope with dying and death (Olson et al., 2010): Nurses can seek support in colleagues, learn coping skills from others, acknowledge the difficulty of coping, and perform healthy personal habits such as exercise, diet, stress reduction activities, and sleep

References

End of Life Care Network. (2011). Key definitions of end of life care. Retrieved on March 17, 2015 from http://www.endoflifecumbriaandlancashire.org.uk/info_patients_carers/definitions.php

Olson, K., Ross, E., Hycha, D., & Cummings‐Winfield C. (2010). End-of-life care. In R. A.Day, P. Paul, B. Williams, S. C Smeltzer, & B. Bare, Brunner & Suddarth’s textbook of Canadian medical‐surgical nursing (2nd ed.) (pp.423-447). Philadelphia, PA: Lippincott Williams & Wilkins.

Silvestri, L. A. (2014). Developmental stages. Saunders comprehensive review for the NCLEX-RN examination (6th ed.) (pp. 265-267). St. Louis, MI: Elsevier

Caregiver BurdenBy: Emily Fuller, Fidaa Hanjoura & Kiran Lidher

Chronic illness affects the entire family. Changes such as family role reversals, conflicts, loss of income, time spent managing illness, decreased family time, and treatment costs can drastically change “normal” family life. These changes can lead to increased stress and caretaker burden/fatigue. (Spencely, 2010)

Caregiver Burden Related Specifically to Cancer:

Cancer patients sometimes require extra support from the family members caring for them. Because of this, the caregiver isn’t as effective in caring for the patient, or themselves. The psychological, behavioural, and physiological effects can negatively impact the caregiver and can lead to the caregiver neglecting their own health. (Bevans & Sternberg, 2012)

Caregiver Burnout:

“The symptoms of caregiver burnout are similar to the symptoms of stress and depression. They include:

Withdrawal from friends, family, and other loved ones Loss of interest in activities previously enjoyed Feeling blue, irritable, hopeless, and helpless Changes in appetite, weight, or both

Changes in sleep patterns Getting sick more often Feelings of wanting to hurt yourself or the person for whom you are caring Emotional and physical exhaustion Irritability” (The Cleveland Clinic Foundation, 2014)

Sandwich Generation:

·   The sandwich generation includes the middle-aged adults (mid 30s-mid 60s) that have the responsibilities of raising their own children and caring for aging parents (Potter, Perry, Stockert and Hall, 2014, p. 369).

·   Middle-aged adults are in the Erikson stage: Generativity vs. Stagnation. Generativity is the willingness to care for and guide others. If generativity is not achieved, stagnation occurs, which is a state manifested by excessive concern with themselves or destructive behaviour toward their children and the community (Potter, Perry, Stockert and Hall, 2014, p. 369).

·   Caring for aging parents is a psychosocial factor affecting middle aged adults. It can have negative effects on the middle-aged individual including:

o   Stress that can affect middle-aged adults overall healtho   Midlife crisis- happens when the person feels turmoil or anxiety about the course

of his or her life and desires change. As a result, the person may change relationships, lifestyle or occupation (Potter, Perry, Stockert and Hall 2014).

o   Financial draining (Day et al, 2010, p. 230).o   Strains can develop if care continues for long term (Day et al, 2010, p. 230).

·   Depending on family dynamics, sometimes aging parents moving in can provide rewarding experiences as the children, their parents, and the children interact and share household responsibilities but it can also be stressful (Day et al, 2010).

Evidence of Caregiver Burden from the Scenario:

Family is primary caregivers James (husband) will be providing her personal care, medications, meals for the family

and doing the housework Janet and James live with her daughter (Jill). Jill has her own family to care for including

her husband (Tom) and daughter (Heather) = Jill and Tom can be considered the sandwich generation

Jill decides to take a leave from work and stay home and help out – financial impact of caregiving

Janet and her family are anxious about increasing her morphine because she does not want to become addicted

Family expresses increasing distress and begins to question their ability to provide care - they feel unprepared and ill equipped

James and Jill wonder about hospice Janet wants to die at home The family feels frustrated

Nursing Strategies to Assist Caregivers:

Working closely with the family can relieve their stress and help them effectively care for Janet. Observe family - how are they handling the situation? Are they able to manage? Work with family to create a care plan and care schedule to reduce caregiver burden Watch for signs of caregiver burnout Teach family about symptom management related to palliation and the care Janet requires

from palliative care nurse Educate family on additional information about resources related to palliative care

available in area. Prepare the family for Janet’s death We can help identify health care needs for both groups (older adult and middle aged

adults) and can assist the multigenerational family in determining the health and community resources available to them as they make decisions and plans (Day et al, 2010).

Resources for Respite Available in Edmonton:

Manas Home Care - Respite Caregivers Edmonton http://www.manashomecare.com/caregiver-respite

Home Instead Senior Care Edmonton - Respite Care https://www.homeinstead.com/3031/home-care-services/senior-care/respite-care

Comfort Keepers - Edmonton Respite Care http://comfortkeepers.ca/local-office/alberta/edmonton/in-home-elder-care-services/respite-care-services/

References

Bevans, M. F. & Sternburg, M. E. (25 Jan 2012). Caregiving Burden, Stress, and Health Effects Among Family Caregivers of Adult Cancer Patients. Journal of American Medical Association, 307(4): 398–403. Doi: 10.1001/jama.2012.29

Day, R. A., Day, R. A., & Brunner, L. S. (2010). Brunner & Suddarth's textbook of Canadianmedical-surgical nursing (2nd ed., pp. 218-255).. Philadelphia: Lippincott Williams & Wilkins.

Mennella, H. (2014). Case-Management: Frail Older Adults. Evidence-Based Care Sheet - CEU. Nursing Reference Center. (2014, February 21).

Potter, P., Perry, A., Ross-Kerr, J.C., Wood, M.J., Astle, B.J., and Duggleby, W. (2014).         Canadian fundamentals of nursing (5th ed., pp. 4-13). Toronto: Elsevier.

Spencely, S. M. (2010). Chronic Illness. In R. A. Day, P. Paul, B. Williams, S. C. Smeltzer, & B. Bare. Brunner & Suddarth’s textbook of Canadian medical-surgical nursing. (2nd ed.) (pp. 171-176). Philadelphia: Lippincott Williams & Wilkins.

The Cleveland Clinic Foundation (2014). Caregiving: Recognizing Burnout. Retrieved from http://my.clevelandclinic.org/health/diseases_conditions/hic_Alzheimers_and_Dementia_Overview/hic_Alzheimers_Disease_The_Role_of_the_Caregiver/hic_Caregiving_Recognizing_Burnout