Acute Care across Care Settings
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Introduction
Acute care demand will continue to increase as a result of continued population growth and ageing (Hirshon et al., 2013). Acute care settings are therefore inevitable nursing scenarios that practitioners have to deal with in the course of their careers. With the increase in routine health issues, acute exacerbation of acute diseases, and life-threatening emergencies along with demographical changes, raising demand for acute care services are due to be experienced (Hirshon et al., 2013). A nurse is therefore required to have competent skills in the management of an acutely ill patient in multiple settings. It for these reasons that the recognition and management of acute care patients remain to be of high priority in the National Health Service agenda. This report discusses the aspects of nursing including management of primary and secondary adult care patients, diagnostic tests, and their importance as well as the effects of physical and psychological effects on patients.
Nursing Management across Care Settings
In different acute care settings, the general signs of deteriorating a patient’s condition have similarities, regardless of the underlying illness (Clarke & Ketchell, 2016). Patients normally require urgent, and short-term treatment for a severe injury, after undergoing surgery routine health issues, or acute exacerbation of a chronic illness. No matter the condition, such patients will present deteriorating respiratory, cardiovascular, and neurological functions (Resuscitation Council, 2011).
In our specific case study, the twenty-nine-year-old, male patient X with childhood asthma presented to the GP nurse C for emergency appointment experience. The first aspect of nursing management will involve primary care under a GP surgery setting. The general practitioner will perform a rapid and objective ABCDE assessment which is used to provide an immediate examination of a patient for the proper management strategies in the emergency department (Thim et al., 2012). The assessment primarily involves a physical evaluation of the patient’s airways, breathing, circulation, disability, and exposure, through brief questions, and assessments of the respiratory system, endocrine, and digestive systems.
In an emergency setting, the ABCDE assessment tool can improve team performance and save valuable time by helping nurses conduct the rapid physical evaluation (Thim et al., 2012). Patient X exhibits non-specific complaints that raise multiple concerns. Upon ABCDE assessment, the GP nurse C gathered crucial information such as evidence of blocked airways, wheezes nor abnormal airflow. They, however, appeared very anxious, shallow breathing, and could not take deep breaths due to the pain. The lack of wheezing sound and acute respiratory rate paints a possible unclear picture of the possibility of an asthma attack. To ascertain the condition, the GP surgery will have to refer the patient to specialist perform a Spirometry test to measure the Forced Vital Capacity (FVC) and Forced Expiration Volume (FEV) and confirm the intensity of the condition.
Abdominal pain is one of the significant aspects of an abdominal pathological assessment (CS & Hardin-Pierce, 2013). The presence of pain in the right iliac fossa, issues with appetite, nausea, and vomiting raises a concern for appendicitis (Findlay et al., 2016)(Findlay et al., 2016). When an adult patient presents pain in the right iliac fossa, the common diagnosis involves acute appendicitis, especially if the pain has a sudden onset, and increasing intensity (Khizer et al., 2009). The physical examination can be conducted by a GP surgery to ascertain inflammation of the peritoneum. This step is also crucial along with blood, and urine tests especially as in the case of Patient X where the condition is an emergency. The blood test must ascertain the White Cell Count and look out for the production of mild leukocytosis (Thim et al., 2012). More advanced diagnosis through ultrasound and CT scanning of the abdomen to help in the confirmation of the condition is also important.
Communication and Diagnostic Tests
With the possibilities of medical errors as a result of communication failure, health care providers and practitioners have a huge role to play. In practice, communication is a primary patient care management setting involves the reporting of all assessments that will be critical in transitioning the patient to another care setting. In the NMC standards (2018), nurses are expected to make use of full rage written, verbal and non-verbal communication tools to acquire, record, and interpret patient’s needs. The key principle of communication competency in the primary and secondary care settings is recognition of anxiety, distress, and early signs of illness in a deteriorating patient in order to guide nurses in making accurate assessments and initiate proper management. Communication of assessments and diagnostic tests results is therefore key in the recommendation and escalation of patient care from one setting to another when necessary.
Standard professional practice requires nurses to use highly effective communication with professional language in all areas of practice. This is important for the purposes of communication between different individuals within different care settings. If improperly and ineffectively done, poor communication will lead to miscommunication which will open other problems including errors, poor quality care, unsafe care and possible sentinel events including injury and unexpected death (Weller, Boyd, & Cumin, 2014). NMC communication standards require nurses to use terms that are recognizable and understandable to their colleagues. In the interaction with the patient, proper communication methods include the use of language that is sensitive to personal needs including cultural and gender-sensitive language.
Deteriorating patients require proper handling; hence, the requirement in nursing is proper and effective communication that is clear, concise, and complete (Webb, 2018). The NMC standard practice requires nurses to be attentive to the patient’s mental health and be of therapeutic help. Mental health attention includes anxiety and distress. Anxiety entails the mental state of nervousness and fear of a situation and what will happen is a common encounter in nursing care management (Yamamoto-Mitani et al.). Annexe A of the NMC Standards of proficiency (2018) recommends the use of a full range of methods to engage patients and use of relationship-building, and communication skills to provide support to distressed patients.
Ensuring that the deteriorating patient understands care decisions, a diverse range of relationships and communication skills are required (Webb, 2018). In patient X’s case, the primary care nurse will be required to recommend the patient to transition to emergency appendicitis for imaging and emergency care under the secondary setting. A timely referral is of the essence in this situation. The GP is therefore required to shorten the time for consultation to avoid the risk of perforation of the appendix and peritonitis. Assisting the patient in coping with fear and anxiety is a key experience for nurses in care management. The first step in helping a patient in an evidently anxious and distressed state involves listening. Active listening is key in knowing what the patient is feeling about their medical situation. The GP nurse in the primary setting must show companion, use positive verbal language and non-verbal cues. Explaining the situation, providing accurate information, and the planned intervention is key in helping patients cope with anxiety.
Physical and Psychological Impact of Elective and Emergency Surgery
In most primary care management settings involving patients with appendicitis, emergency surgery must be scheduled to remove the appendix as soon as possible through appendectomy (Clarke & Ketchell, 2016). This is because the condition can be life-threatening with possible peritonitis complications as a result of the rapturing of the appendix if left untreated (Findlay et al., 2016). Like any other surgical procedure, the appendectomy process may pose significant impacts on the patient.
Presently, studies have shown that appendicitis requires emergency semi elective surgery procedure in order to preserve life (Kim et al., 2015). The physical and psychological impact of an elective surgery revolves around the quality of life for the patient and possible complications. Due to the severity of patient X‘s condition, waiting for elective surgery is likely to worsen the general health perception, increase the patient’s level of anxiety and cause issues with the quality of life. The emotional cycle of going from GP consultation to waiting for an elective appendectomy procedure will deal with the patient with marginal physical and physiological distress and further deteriorating of the condition. Delayed appendectomy for more 24 hours can lead to complications including perforation or rupturing of the appendix. In case this happens, peritonitis will be inevitable, causing leakage of contents into the abdomen. The patient will experience intense and constant pain in the entire abdomen, increased fever, increased heart rate and breathing, muscle rigidity, alteration of serum electrolyte level and elevation of WBC.
Despite the negative impacts of appendectomy on the patient’s quality of life, elective surgery can produce positive outcomes. In contrast with emergency appendectomy, semi-elective appendectomy allows patients to come in terms with the procedure and prepare themselves psychologically. Semi-elective surgery allows for psychological intervention and is, therefore, likely to result in low levels of psychological distress including anxiety and improved recovery behavior (Kim et al., 2015). They may therefore cope with the situation in a better manner compared to emergency surgery. In terms of outcomes, psychological preparation can reduce negative outcomes by reducing pain sensation, increase the healing process of wounds through psychoneuroimmunology (Maple et al., 2015).
With appendectomy being an emergency procedure, the psychological effects might only manifest after the surgery due to prolonged healing, causing physical effects. The process involves a 2-4 inch long incision on the abdomen (laparotomy) or via several small incisions (laparoscopic surgery) (Humes & Simpson, 2006). Patients who undergo any of the two have to adjust their lifestyle during the recovery process. Patients who undergo laparoscopic surgery are particularly limited in terms of physical activity for about 10-14 days. However, in most cases, the physical effect is always sorted with deteriorating patients’ emergency surgery. Pinto et al. (2016) state that Patients may be affected psychologically due to surgical complications resulting from long-lasting disability prolonged recovery. Physical effects of post-surgery include pain; wound swelling, which often depend on the surgery procedure or how well one can cope with the pain. Physical effects, such as wound healing, may prove futile due to psychological distress
In the case of elective surgery, the patient also undergoes physical effects depending on the symptoms. Waiting for Elective surgery prolongs primarily the suffering due to symptoms relieved by surgery (Theunissen et al., 2014). Such symptoms are pain, as depicted in Patient A’s case. If the Doctors prefer the elective surgery, then Patient A will have to bear with the pain given that the pain is severe.
Conclusion
In conclusion, chronic disease management relies on integration across community care settings and acute care settings. Joint association and many medical associations have given SBAR a green as the standard communication in healthcare settings. In deteriorating patients, as in the case of Patient A requires effective communication from both general practitioners and acute practitioner settings. Question about clinical care skills or knowledge can arise, considering the nurse’s ability to communicate well to deteriorating patients. Both surgical elective and emergency procedures result in psychological effects on the patient because of their distress. Elective surgery temporarily withholds surgery benefits as opposed to an emergency response where the patient gets the treatment and starts the healing period.
Appendix A
Primary and Secondary Assessment of an Adult
Early identification of clinical deterioration is important in preventing subsequent cardiopulmonary arrest and reducing mortality. By closely monitoring changes in physiological observations, deteriorating patients are more likely to be identified before a serious adverse event occurs.
Patient Details
| Name: : Archie Hammond | Age: 29 Sex: M Allergies: No known allergies
Height: 1.75m Weight: 75Kg |
| Past Medical History
|
Childhood asthma
Takes no regular medication |
| Presenting Complaint
|
Has presented to the GP surgery for an emergency appointment this morning.
7-day history of nausea and vomiting with subsequent reduced nutritional intake Moderate abdominal pain in the right iliac fossa radiating to the umbilical area. Started 12 hours ago and initially came and went, however, it is now constant and increasing in intensity, now 8/10 on the pain scale. |
| Diagnosis
|
Appendicitis |
Primary Assessment
Airway Assessment
| Assessment | Results of Assessment | Action Taken /If none taken why? |
| Look
– Chest movement – Signs obstruction in the mouth |
No evident airway obstruction
No evidence of cyanosis Some use of accessory muscles Appears very anxious and restless |
Airway is patent -no intervention needed. |
| Listen
– Can the patient talk in full sentences – Is there any respiratory noises i.e. stridor/ gurgling |
Not able to speak in full sentences as limited by pain, but has
normal voice. No evidence of wheeze or stridor
|
Airway is patent. No sign of obstruction. |
| Feel
– Can you feel breath on your face |
Evidence of normal air flow in and out of the mouth | Airway is patent. |
| Check for Laryngectomy/tracheostomy | ||
| – If airway not patent when assessed by Look, Listen, Feel, open airway with head tilt chin lift/jaw thrust
– Consider suction |
Do not move onto breathing assessment until airway patency is assured
Breathing Assessment
Patient airway does not ensure adequate ventilation. Adequacy of breathing needs to be assessed
| Assessment | Results of Assessment | Action Taken /If none taken why? |
| Respiratory Rate | 24 bpm | Encourage Mr. Hammond to take deep breathing exercise and reposition patient in high fowler position. |
| Respiratory Depth | Shallow breathing, unable to take deep breaths due to pain.
|
Ask the registered nurse to check if there is prescribed pain relief.
Check for bilateral chest expansion. |
| Respiratory Rhythm | ||
| Use of Accessory Muscles | Yes, appears to be using intercostal muscles | |
| Oxygen Saturations | 93% on room air | Reposition to high fowler position
Recheck the saturation with the sat probe on the other hand. Check if he is been prescribed with O2, if is been prescribed, then ask the registered nurse to administer O2 but if there is non then ask the doctor to prescribed. |
| Inspect chest for
– Size – Shape – Symmetry of expansion – Presence of scars , wounds, drains |
||
| Listen to Respiratory Noises
– Stridor (inspiratory) – Wheeze (expiratory) – Grunting – Gasping – No noise – Cough (strong/weak/productive, type of secretions) |
Reduced breath sounds on auscultation, but no added sounds. No evidence of cough |
Circulation Assessment
| Assessment | Results of Assessment | Action Taken /If none taken why? |
| Assess peripheries for:
– Colour – Temperature – Condition – Determine capillary refill time |
Skin feels dry
Increased skin turgor Dry mucous membranes Looks pale and sweaty 37.6C
|
Offer and encourage Mr. Hammond to plenty of water as he might be dehydrated. |
| Assess pulse for:
– Rate – Rhythm – Volume |
120 bpm
Feels regular and normal volume |
ECG with the supervision with the registered nurse |
| Obtain BP | 100/60 mmHg | Ask patient what his normal B/P is.
Encourage oral intake but if patient continue vomiting. Check if there is IVI prescribed as patient might be dehydrated. |
| Assess fluid status
– Mucous membranes – Urine output – Drains/stoma fluid loss – Fluid intake – Estimate fluid balance |
CRT 3 seconds
Feels very thirsty Passed urine once today, is dark in colour and a reduced volume |
Commence fluid balance
Encourage oral intake |
Disability Assessment
| Assessment | Results of Assessment | Action Taken /If none taken why? |
| A – Alert | alert | |
| V – Responds to Voice | ||
| P – Responds to Pain | ||
| U – Unresponsive | ||
| Pupillary size | 3 | |
| Pupillary reaction | Equal and constrictive to light | |
| Blood glucose | 6.5 mmol/L | Normal blood sugar |
| Assess Pain
– PQRST – Pain Score |
Pain score 8/10 in the lower right quadrant of the abdomen.
Pain feels sharp and ‘tearing’ and is constant |
Offer regular pain killer as prescribed. |
Modified Secondary Assessment
Takes place once vital functions have been assessed and initial treatment of life threatening illness has been started.
Exposure/External Assessment
| Assessment | Result |
| Core temperature | |
| Observe skin:
– Oedema – Redness/rashes – Bruising, grazes/lacerations |
Skin looks slightly sweaty
No obvious wounds or lesions Skin in good condition and healthy
|
| Assess Abdomen
– Wounds/sutures/drains – Distention/soft/tense – Bowels – Vomiting |
Very painful abdomen on palpation
Very loud bowel sounds Has not opened bowels for 2 days Constant nausea past 48 hours with frequent vomiting (approx 4-5 times a day). |
| Note presence of IVs/Catheter/NGT?PEG etc | |
| Anti-embolic stockings? |
Full Patient Assessment
| Assessment | Result |
| Review Medical notes and Observations Charts | |
| Review Drug Chart | |
| Review investigations/tests | |
| Social History | Student
Lives in a shared house whilst completing an MSc in Engineering Has not travelled abroad recently Family (father and sister) lives in Cornwall
|
| Drugs | Drugs | Drugs |
| Investigations | Time | Results |
| At the GP | Suspected appendicitis | |
| Full set bloods | Emergency Department | Not specified |
| Venous blood gas | Emergency Department | Not specified |
| 2 lead ECG | Emergency Department | Not specified |
| CT abdomen | Emergency Department | Not specified |
Goals
| Assessment | Result |
| Physiological Monitoring Plan
– Identify frequency – Identify type |
Mr Hammond was anxious and in pain.
Need reassurance all the time and over pain killer. |
| During the assessment demonstrates:
– Maintenance of privacy and dignity – Effective communication and escalation skills utilizing a recognized tool. I.e. SBAR |
Ask patient consent to obtain an assessment.
The close curtain before assessing the patient.
|
| Assessment conducted promptly | |
| Adheres to infection control practices | Correct handwashing and wear proper PPE |
| Report findings to senior nurse/doctor | |
| Yes | No – Why Not? |
| SBAR | Comments |
| Situation
|
Patient news2 scale of 8 and potential deterioration. |
| Background
|
Mr. Hammond, 29-year-old with no known of allergies. Admitted in ED via his GP due to 7 days history of nausea and vomiting with subsequent reduced of appetite. Was reported pain scale 8/10 on his abdominal in the right iliac fossa radiating to the umbilical area.
|
| Assessment
|
Upon assessment, Patient News 2 scale of 8 due to high respiration 24 BPM, sat 93% on air, blood pressure systolic of 100 and heart rate of 120. Patient is alert but he is using accessory muscle and unable to speak in full sentence. Patient feels dry with poor oral intake and output. |
| Recommendation
|
The patient sat up on a high fowler position, we recommend administering O2, regular pain killer, and advice for IVI as the patient vomiting and poor oral intake. ECG was taken but need reviewing. |
| Treatment Plan | Pain management |
| Additional Information |
|
|
| Opportunities to discuss Health Promotion? |
| Any recommendations?
|
Appendix B
OSCE ACACS adapted NEWS 2 Chart 2020
| NEWS Key | Full name: Archie Hammond |
| O 1 2 3 | Date of birth: 03/10/91 Date of admission: 19/01/2021 |
| Date | 19/01/20 | |||||||||||||
| Time | 12:20 |
| A+B A + B | >25 | 3 | ||||||||||||
| Respirations
Breaths/min |
21 – 24 | 24 | 2 | |||||||||||
| 18 – 20 | ||||||||||||||
| 15 – 17 | ||||||||||||||
| 12 – 14 | ||||||||||||||
| 9 – 11 | 1 | |||||||||||||
| < 8 | 3 | |||||||||||||
| A + B | > 96 | |||||||||||||
| Oxygen supplement | 94 – 95 | 1 | ||||||||||||
| SpO2 Scale 1
Oxygen saturation % |
92 – 93 | 93 | 2 | |||||||||||
| < 91 | 3 | |||||||||||||
| SPo2 Scale 2 ↑ | > 97 on O2 | 3 | ||||||||||||
| Oxygen saturation (%) | 95 – 96 | 2 | ||||||||||||
| Use Scale 2 if the target range is 88-92% | 93 – 94 on O2 | 1 | ||||||||||||
| E.g.in hypercapnic | >93 on air | |||||||||||||
| Respiratory failure | 88 – 92 | |||||||||||||
| * ONLY Scale 2 under the direction of a | 86 – 87 | 1 | ||||||||||||
| Qualified clinician | 84 – 85 | 2 | ||||||||||||
| < 83% | 3 |
| Airway or Oxygen | A=Air | |||||||||||||
| O2L/min | 2 | |||||||||||||
| Device |
| C | > 220 | 3 | ||||||||||||
| Blood pressure | 201 – 219 | |||||||||||||
| mmHg | 181 – 200 | |||||||||||||
| Scores use systolic | 161 – 180 | |||||||||||||
| BP only | 141 – 160 | |||||||||||||
| 121 -140 | ||||||||||||||
| 111 -120 | ||||||||||||||
| 101 -110 | 1 | |||||||||||||
| 91 – 100 | 100 | 2 | ||||||||||||
| 81 – 90 | 3 | |||||||||||||
| 71 – 80 | 3 | |||||||||||||
| 61 – 70 | 3 | |||||||||||||
| 51 – 60 | 3 | |||||||||||||
| < 50 | 3 |
| C | >131 | 3 | ||||||||||||
| Pulse | 121-130 | 2 | ||||||||||||
| 111-120 | 120 | 2 | ||||||||||||
| Beats/min | 91-110 | 1 | ||||||||||||
| 71-90 | ||||||||||||||
| 61-70 | ||||||||||||||
| 51-60 | ||||||||||||||
| 41-50 | 1 | |||||||||||||
| <40 | 3 |
| D | Alert | alert | ||||||||||||
| Consciousness | Confusion | 3 | ||||||||||||
| Score for NEW | V | 3 | ||||||||||||
| Onset of confusion | P | 3 | ||||||||||||
| (no score if chronic) | U | 3 |
| E | > 39.1 | 2 | ||||||||||||
| Temperature | 38.1 – 39.0 | 1 | ||||||||||||
| oC | 37.1 – 38.0 | 37.6 | ||||||||||||
| 36.1 – 37.0 | ||||||||||||||
| 35.1 – 36.0 | 1 | |||||||||||||
| < 35.0 | 3 |
| NEWS TOTAL | 8 |
| Monitor frequency | Continuous monitoring
Every 15mins |
|||||||||||||
| Escalation of care Y/N | yes | |||||||||||||
| Initials | MG |
References
Clarke, D., & Ketchell, A. (2016). Nursing the Acutely Ill Adult (2nd ed. 2017 edition). Red Globe Press.
CS, K. D. W. R. M., & Hardin-Pierce, M. (2013). High-Acuity Nursing (6th edition). Pearson.
Cutler, L., & Cutler, J. (2010). Critical Care Nursing Made Incredibly Easy!: Uk Edition (First, UK ed edition). Lippincott Williams & Wilkins.
Davy, C., Bleasel, J., Liu, H., Tchan, M., Ponniah, S., & Brown, A. (2015). Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review. BMC health services research, 15(1), 1-11. https://doi.org/10.1186/s12913-015-0854-8
Findlay, J. M., el Kafsi, J., Hammer, C., Gilmour, J., Gillies, R. S., & Maynard, N. D. (2016). Nonoperative management of appendicitis in adults: A systematic review and meta-analysis of randomized controlled trials. Journal of the American College of Surgeons, 223(6), 814–824.
Hirshon, J. M., Risko, N., Calvello, E. J., Ramirez, S. S. de, Narayan, M., Theodosis, C., & O’Neill, J. (2013). Health systems and services: The role of acute care. Bulletin of the World Health Organization, 91, 386–388.
Humes, D. J., & Simpson, J. (2006). Acute appendicitis. BMJ : British Medical Journal, 333(7567), 530–534. https://doi.org/10.1136/bmj.38940.664363.AE
Khizer, M., Ram, S., & Khan, A. M. (2009). A rare cause of right iliac fossa pain. Journal of Indian Association of Pediatric Surgeons, 14(1), 34–35. https://doi.org/10.4103/0971-9261.54812
Kim, S. H., Park, S. J., Park, Y. Y., & Choi, S. I. (2015). Delayed Appendectomy Is Safe in Patients With Acute Nonperforated Appendicitis. International Surgery, 100(6), 1004–1010. https://doi.org/10.9738/INTSURG-D-14-00240.1
Maple, H., Chilcot, J., Lee, V., Simmonds, S., Weinman, J., & Mamode, N. (2015). Stress predicts the trajectory of wound healing in living kidney donors as measured by high-resolution ultrasound. Brain, Behavior, and Immunity, 43, 19–26. https://doi.org/10.1016/j.bbi.2014.06.012
Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open, 8(8). https://doi.org/10.1136/bmjopen-2018-022202
Pérez Rivas, F. J., Martín‐Iglesias, S., Pacheco del Cerro, J. L., Minguet Arenas, C., Garcia Lopez, M., & Beamud Lagos, M. (2016). Effectiveness of nursing process use in primary care. International journal of nursing knowledge, 27(1), 43-48. https://doi.org/10.1111/2047-3095.12073
Pinto, A., Faiz, O., Davis, R., Almoudaris, A., & Vincent, C. (2016). Surgical complications and their impact on patients’ psychosocial well-being: a systematic review and meta-analysis. BMJ open, 6(2).
Resuscitation Council. (2011). Immediate Life Support 3rd edn.
Shahid, S., & Thomas, S. (2018). Situation, Background, Assessment, Recommendation (SBAR) Communication Tool for Handoff in Health Care – A Narrative Review. Safety in Health, 4(1), 7. https://doi.org/10.1186/s40886-018-0073-1
Theunissen, M., Peters, M. L., Schouten, E. G., Fiddelers, A. A., Willemsen, M. G., Pinto, P. R., Gramke, H. F., & Marcus, M. A. (2014). Validation of the surgical fear questionnaire in adult patients waiting for elective surgery. PloS one, 9(6), e100225. https://doi.org/10.1371/journal.pone.0100225
Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine, 5, 117–121. https://doi.org/10.2147/IJGM.S28478
Webb, L., 2018. Exploring the characteristics of effective communicators in healthcare. Nursing Standard. https://doi.org/10.7748/ns.2018.e11157
Weller, J., Boyd, M., & Cumin, D. (2014). Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal, 90. https://doi.org/10.1136/postgradmedj-2012-131168
Yamamoto-Mitani, N., Noguchi-Watanabe, M., & Fukahori, H. (2016). Caring for Clients and Families With Anxiety. Global Qualitative Nursing Research, 3. https://doi.org/10.1177/2333393616665503