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)