[Case Study ]: Forearm Cellulitis at the Arteriovenous Fistula site.

Forearm Cellulitis

According to Stolic (2012), 20% of all arteriovenous fistula (AVF) complications are infections. These infections which usually manifest as edema and erythema can be easily treated.  This indicates the need for an increased awareness about AVF complications and ways to prevent them. This paper will focus on infection as a complication of AVF and the typical diseases that can make a patient get an AVF.

Basic Conditioning Factors

 The patient  is a male.  His current diagnosis were AV shunt forearm cellulitis, end stage kidney disease, and diabetes.  He has a past medical history of stroke, hypertension (HTN), diabetes mellitus (DM), methicillin-resistance staphylococcus aureus (MRSA), end-stage renal disease (ESRD), pseudoaneurysm of arteriovenous fistula (AVF). 

In Ericks Erickson’s stages of psychological development, (Leifer & Fleck, 2013) state that the patient falls into the generativity versus stagnation stage. Those who contribute in a positive way to family or community fall under generativity while those who fail to achieve generativity fall into stagnation. People who fall under stagnation care only about themselves and are in total denial of the developmental process.

Anatomy and Physiology of the Involved Organs

The Skin

Hinkle and Cheever (2014) states that the skin is the largest organ system and it is an essential part of life. It acts as a barrier between external and internal environment. It is made up of three layers, epidermis, dermis, and subcutaneous tissues. The epidermis is the external layer and it is replaced every three to four weeks. The replaced dead cells hold large amount of keratin which forms the outer barrier of the skin. This keratin also has the ability to repel and prevent excessive fluid loss from the body. The junction of the epidermis and dermis called the rete ridges, anchors the epidermis to the dermis and also permits the free exchange of essential nutrients between the two layers.

The dermis which is the middle layer, makes up the largest portion of the skin. It also provides the skin with strength and structure. It holds blood and lymph vessels, nerves, sebaceous glands, sweat, and hair roots. The innermost layer known as the subcutaneous tissue or hypodermis provides a cushion between the skin layers, muscles and bones. The hypodermis promotes skin mobility, molds body contours and insulates the body. The skin provides effective protection against invasion by bacteria and other foreign matters, monitors the condition of immediate environment, prevents excessive fluid loss, regulates temperature and synthesizes vitamin D (Hinkle & Cheever, 2014).

The Kidney

 The kidneys are located behind and outside the peritoneal cavity at the posterior wall of the abdomen. They are brown in color and shaped like a bean. The average weight of an adult kidney is approximately 113 to 170 grams, 10 to 12 centimeters in length, and about 2.5 centimeters. The location of the liver makes the right kidney slightly lower than the left kidney. The kidneys are both protected internally by the fat deposits around them and eternally by the ribs and the muscles of the back and abdomen. The kidney is composed of two parts, the renal cortex and medulla. The cortex holds the nephrons, the structural and functional units of the kidney (Hinkle & Cheever, 2014).

The nephrons handle filtration and excretion of waste products and formation of urine. The other part of the kidney called the medulla is the inner portion of the kidney. It contains the loops of Henle, the vasa recta and the collecting ducts. Functions of the kidney in the body includes formation of urine, regulation of blood pressure, maintenance of balance between fluid and electrolytes, formation of red blood cells, regulation of acid – base balance, renal clearance, excretion of waste products and synthesis of vitamin D for the absorption` of calcium. The formation of urine involves three complex steps, filtration in the glomerulus, tubular reabsorption, and tubular secretion. These filtrates include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. Among these filtrates, some are reabsorbed, and others are secreted. Creatinine is the only filtrate that is never reabsorbed (Hinkle & Cheever, 2014).

Blood filtration occurs through the glomerular filtration in the kidney. The normal blood flow through the kidney ranges between 1000 and 1300 ml/min. About 180 L of filtrates passes through the glomerulus, and 99% of the filtrates gets reabsorbed into the bloodstream leading to  2 liters of urine each day (Hinkle & Cheever, 2014).

The Pancreas

The pancreas which performs both exocrine and endocrine functions is located in the upper part of the abdomen. The exocrine function of the pancreas secretes digestive enzymes which are collected in the pancreatic duct. The endocrine portion of the pancreas is a collection of cells embedded in the pancreatic tissue. The endocrine pancreas is composed of alpha, beta, and delta cells. The alpha cells secrete glucagon, the beta cells secrete insulin while the delta cells secrete somatostatin (Hinkle & Cheever, 2014).

Pathophysiology of the all involved diseases

Diabetes Mellitus

Diabetes mellitus (DM) is a major chronic disease in the world. A major risk factor of DM is age. It has a high prevalence among African Americans, Asian American, and Latin Americans (Bigelow & Freeland, 2017). It is prevalent in people over 40 years old, and therefore called adult onset diabetes mellitus or type 2 diabetes. In type 2 diabetes, the pancreas produces insulin, but the body cannot use it. The body’s intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver (Hinkle & Cheever, 2014).

Symptoms include fatigue, irritability, polyuria, polydipsia, polyphagia, poor wound healing, vaginal infections, tingling & numbness in the hands or blurred vision. An abnormally high glucose level is the basic criterion for the diagnosis. Fasting plasma glucose (FPG), random plasma glucose, and glucose level 2 hours after receiving glucose may be used (Hinkle & Cheever, 2014). DM diagnosis in the older population is the same in the younger population ( Bigelow & Freeland, 2017).

 The main goal is to normalize insulin activity and glucose levels to reduce the development of complications. Intensive treatment includes three to four insulin injections per day or an insulin pump, plus frequent blood glucose monitoring. The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia, while keeping a high quality of life.

Diabetes management has 5 components: nutritional therapy, exercise, blood sugar monitoring, pharmacological therapy, a patient education. DM can involve treatment of a wide variety of physiologic disorders, depending on the patient’s health status. Glucose control is important. Avoidance of potential complications and educating patients is also important (Hinkle & Cheever, 2014).

Diabetes mellitus injures the blood vessels, especially the arterioles. Renal arteries are commonly injured. When high glucose levels in the renal arteries damage the kidney, waste products gets to accumulate in the body. The complication leads to  chronic renal disease or ESRD (Hinkle & Cheever, 2014).

 End Stage Renal Disease

Chronic kidney disease (CKD) is a general term that refers to the decrease in glomerular filtration rate (GFR) for three months or more or damage in kidney function. The primary cause of CKD is diabetes, and the secondary cause is hypertension. The other causes are pyelonephritis, congenital disorders, and glomerulonephritis. If CKD is left untreated, it will lead to ESRD (Hinkle & Cheever, 2014). 2017 estimate shows that between 10% and 15% of adults in the United States may have CKD. More than half a billion American adults are on dialysis from their ESRD, African Americans have the highest prevalence rate (Norton, Newman, Romancito, Mahooty, kuracina, & Narva,  2017). ESRD is the final stage of kidney disease, which results in retention of uremic waste products from breakdown of protein. ESRD usually leads to the need for kidney replacement therapies, dialysis for waste product removal, or kidney transplantation. Chronic renal disease is classified into five various stages, according to the GFR of the kidney, with the normal GFR being 90ml/min to 125mL/min (Hinkle & Cheever, 2014).

Stage one is classified with GFR greater than or equal to 90mL/min. In this stage the kidney is damaged, yet the GFR is still normal. In stage two, the GFR is equal to 60 to 89 mL/min, with a mild decrease in GFR. The third stage is classified with a GFR of 30 to 59 mL/min with a moderate decrease in GFR. The fourth stage which is the severe decrease in GFR, has a GFR level of 15 to 29 mL/min. The fifth and final stage is the end-stage kidney disease, which has a GFR less that 15 mL/min (Hinkle & Cheever, 2014).

The signs and symptoms of ESRD involves neurologic, integumentary, cardiovascular, pulmonary, GI, hematological, reproductive, and musculoskeletal systems. The neurological systems involve, inability to concentrate, disorientation, tremors seizures and behavioral changes. The integumentary system includes, dry, flaky skin, pruritus, ecchymosis, coarse, thinning hair, ecchymosis, and gray skin color. Cardiovascular system includes pitting edema, hyperkalemia, hyperlipidemia, pericardial effusion, pericardial tamponade, pericarditis. Pulmonary changes include auscultation of crackles, kussmaul-type respiration, thick sputum, uremic pneumonitis. GI changes are ammonia odor to breath, metallic taste, constipation, diarrhea, bleeding from GI and anorexia. Hematological changes include, anemia and thrombocytopenia. Reproductive changes include, infertility decreased libido, and testicular atrophy. Musculoskeletal changes include, muscle cramps, foot drops, renal osteodystrophy, and bone pain (Hinkle & Cheever, 2014).

The assessment and diagnostics of ESRD are elevated serum creatinine and blood urea nitrogen (BUN), anemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, hyperkalemia, fluid retention, uremic pericarditis, uremic pneumonitis, hyperkalemia, hyponatremia. The serum creatinine is the best indicator of CKD, because it is specifically the product of muscle breakdown. Anemia ensues because the kidneys cannot produce erythropoietin for production of red blood cells (RBCs). Metabolic acidosis occurs when the body becomes acidic. In this case, the waste products in the body cannot be excreted and they become toxic to the body (Hinkle & Cheever, 2014).

The pharmacological therapy includes the use of angiotensin-converting enzyme inhibitors (ACE inhibitors), beta adrenergic blockers, phosphate and calcium binders, anti-seizure agents. Calcium and phosphate binders bind to dietary phosphorus in the Gastrointestinal tract (GI tract) to treat hyperphosphatemia and hypocalcemia. Beta adrenergic blockers and ACE inhibitors are hypertensive medications for the treatment of increased vascular pressure. Anti-seizure medications treat seizures due to high uremic waste in the body. Erythropoietin is also given to stimulate the production of red blood cells. Dialysis is started to help excrete the toxin waste from the body (Hinkle & Cheever, 2014).

 Nursing management involves monitoring fluid and electrolyte balances, by carefully selecting the patient’s intravenous (IV) solutions, checking urine output, assessing for edema, assessing alteration in heart sounds, breath sounds, accurate daily weights and recording of intake and outputs. The nurse also tries to reduce metabolic rate by reducing fever and infection, and ensuring the patient is on bedrest. The nurse encourages the patient to turn, cough, and take deep breaths to prevent atelectasis and reparatory tract infections. Proper skin care is provided, because of edema and high levels of uremia (Hinkle & Cheever, 2014). Reducing sodium intake for CKD will help control BP, lower urine albumin levels and increase the effects of hypertensive medications (Norton, et al., 2017).

The goal of medical management is treatment of underlying causes, maintenance of kidney function and hemostasis. Treatment of underlying causes includes regular monitoring of blood pressure, regular blood glucose checks to avoid hyperglycemia, smoking cessation, weight management, managing anemia, decrease in sodium and alcohol (ETOH) consumption. These can be achieved using medication and nutritional therapy, dialysis, and kidney transplant (Hinkle & Cheever, 2014).

Dialysis is used when there is an incidence of is hyperkalemia, a state of fluid overload, acidosis, advanced uremia, and pericarditis. Chronic or maintenance dialysis is used in CKD and ESRD. A common type of dialysis used is hemodialysis. Hemodialysis is not a cure for ESRD, rather it prevents death. The goal is to remove toxic nitrogenous substances and excess fluid from the blood. In order to carry out this goal, a vascular access is needed. AVF is a type of vascular access. Among others like arteriovenous graft, and double lumen, AVF is the preferred method of vascular access for dialysis (Hinkle & Cheever, 2014).

AVF is created surgically, usually in the forearm (at the brachial artery and cephalic vein in the antecubital fossa) by anastomosing an artery to a vein, either side-to-side, end-to-side, or end-to-end (Kossman & Himmele, 2015). This access will need about two to three months to mature, before it can be used (Hinkle & Cheever, 2014). End-to-end anastomosis needs a more difficult surgery and can lead to ischemia of the distal extremities, especially in the elderly and patients with DM. Side-to-side anastomosis can lead to venous hypertension, even though it is technically easier. The most acceptable option is the end-to-side anastomosis. After surgery, complications such as infections, thrombosis, and false aneurysm may occur (Stolic, 2012). The complication that is of most importance to this paper, is infection at the site of the AVF.

Cellulitis

Cellulitis occurs when an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissue. The pathogen is normally streptococcus species or staphylococcus aureus. Cellulitis has an acute onset of swelling, localized redness, warmth, and pain. It is associated with systemic signs of fever, chills, and sweating. The redness may not be uniform and often skips areas and eventually develops a pitting ‘orange peel’ appearance. Regional lymph nodes may also be tender and enlarged (Hinkle & Cheever, 2014).

Chang, Geng-He; Tsai, Ming-Shao; Liu, Chia-Yen; Lin, Meng-Hung; Tsai, Yao-Te; Hsu, Cheng-Ming; Yang, Yao-Hsu, (2017), states that patients who have ESRD are predisposed to infections because they are immunosuppressed. They have a higher mortality and morbidity rate than those without ESRD. Stolic (2012), states that infection accounts for 20% of all AVF complications. Most AVF infections involve perivascular cellulitis. Clinical manifestations of AVF arises after visible signs of inflammation at the site of vascular access with or without systematic manifestations. Localized infections occurring after AVF are treated with the appropriate antibiotics. The appropriate antibiotics are determined after culture and sensitivity studies.

Mild causes of cellulitis can be treated on an outpatient basis with oral antibiotics. If severe, patient is treated with IV antibiotics. The key to preventing recurrent episodes of cellulitis lies in adequate antibiotic therapy for the initial event and in identifying the site of bacterial entry. The patient is instructed to elevate the affected area and apply cool, moist packs to the site every two to four hours until the inflammation has resolved and then transition to warm moist packs. Education should focus on preventing a recurrent episode (Hinkle & Cheever, 2014).

The patient in this case study, is currently on hemodialysis as a result of DM complications. His diabetes was not managed well, this damaged his kidney. The chronic kidney disease went from stage 1 through 5. Hinkle and Cheever (2014), states that at this stage, the GFR is less than 15. The patient was placed on hemolysis as a result of his decreased GFR level. A vascular access was created for his dialysis on his left  forearm at the brachial artery and cephalic vein in the antecubital fossa (Stolic, 2012). Prior to his admission, he got a bug bite at his vascular site. The bug bite lead to infection. A culture and sensitivity test was conducted. The test was positive for MRSA. This gram-positive bacterium was tested against a variety of antibiotics like clindamycin, erythromycin, oxacillin, penicillin, trimethoprim/sulfa, and vancomycin. It showed sensitivity to clindamycin, trimethoprim/sulfa, and vancomycin.

Vancomycin was the antibiotic of choice for treatment. Vancomycin 750mg IV was ordered to be infused over one hour. 

The perivascular infection at the AVF site had to be covered with gauge, to prevent further infection, and promote healing. A temporary vascular site for dialysis was created, for the previous site was damaged. A hemodialysis port called perma cath was placed on his right chest wall. In the mean time, the patient was to meet with the vascular surgeon to discuss creation of a new permanent vascular site for hemodialysis.

                                                                  Medical orders

The patient’s attending physician placed him on a renal diet because he is in end-stage kidney disease. Renal diet is primarily low sodium, low protein, and fluid restrictions. The attending physician also requested that he should be assisted with getting out of the bed, either with a nurse, a cane or walking stick.

Activity and Diet

Regarding the patient’s renal diet, he ate 50% of his food, which is good. He tolerated his diet well. No nausea or vomiting was noted during the shift. The patient was noncompliant with his ordered activity. He chose to get out of bed without assistance and stated that he did not need or want help getting out of bed. He got out of bed and to the bathroom without any form assistant during shift.

Medications

Generic/ trade Class & subclass	Dose Range Ordered dose (OD), route	Action	Reason prescribed	Nursing Responsibilities / Pt. teaching
Amlodipine (Norvasc) Antihypertensive Calcium channel blocker (CCB)	5-10 mg (OD:10mg) By mouth (PO)	Inhibits the transport of calcium into myocardial and vascular smooth muscle	Hypertension (HTN)	1. monitor blood pressure and pulse before drug therapy. 2. monitor echocardiogram (ECG) periodically 3. monitor intake and output (I&O) 4. Hold for low blood pressure 5 May cause drowsiness or dizziness. 6.Notify Health care provider (HCP) if any dyspnea, edema.
Aspirin (ASA) Non-opioid analgesics / antiplatelet aggregation/ antipyretic	81- 325mg (OD: 81mg) PO	Decreases platelet aggregation	To prevent Myocardial Infarction (MI)/ Cardiovascular Disease    (CVA)	1. Monitor for bleeding 2. No concurrent use of ETOH to minimize Gastrointestinal (GI) irritation.
Clonidine (catapres) Antihypertensive	0.1 – 0.3mg (OD:0.1 mg) PO	stimulates alpha-adrenergic receptors in the central nervous system (CNS) inhibiting cardio acceleration and vasoconstriction centers leading to a decrease in sympathetic outflow		1. Hold for low blood pressure (BP) 2. Notify HCP if pruritus develops
Docusate (docusate calcium) Laxative / stool softener	100 mg PO	Promotes incorporation of water into stool resulting in softer fecal mass.	Prevents constipation for iron supplement	1. Assess for abdominal distention, presence of bowel sounds and usual pattern of bowel function. 2. This is for short term use only.
Ferrous sulfate (Iron supplements) Antiemetics/ iron supplements	195 – 325mg (OD: 325mg)	Enters the bloodstream and gets transported to the liver, spleen and bone marrow to become part of iron stores.	Iron deficiency anemia	1. Administer 1 hour (hr.) before meals (AC) or 2 hrs. after meals (PC) 2. Stool may become dark green.
Furosemide (Lasix) Diuretics / Loop diuretics	20 -80mg 80 mg PO	Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increase renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.	ESRD /HTN	1. Monitor BP and Hold for low BP. 2. Monitor for hypokalemia 3. Monitor flood intake and urine output.
Insulin glargine (Lantus) Antidiabetic agent	SQ	Decreases blood glucose by transporting glucose into cells.	Diabetes	1. Hold if hypoglycemic 2.Request for a cup of juice if hypoglycemic.
Insulin Lispro Antidiabetic agent	SQ	Decreases blood glucose by transporting glucose into cells.	Diabetes	1. Administer when 50% of food has been eaten. 2. Assess for hypoglycemia at peak times
Metoprolol ER (Lopressor) Antianginals/ Antihypertensives Beta- blocker	25 – 100mg (OD:50 mg)	Blocks stimulation of beta-adrenergic receptors	HTN MI prophylactic	1. Decrease BP and Heart Rate (HR) 2. Fatigue
Sevelamer (Renagel) Electrolyte modifiers/ Phosphate binders	800 -1600mg (OD:1600 mg)	A polymer that binds phosphate in the GI tract, prevents its absorption.	-High serum phosphorus level and low Calcium level -ESRD	1. Give with meals
Sitagliptin (Januvia) Antidiabetics/ Enzyme inhibitor	25mg -10mg (OD:25mg)	Inhibits the enzyme which slows the inactivation of incretin hormones, which leads to an increase in levels of active incretion hormones, which increases insulin release and decrease in glucagon levels.		1. Monitor blood glucose levels

          (Vallerand, Sanoski, & Deglin, 2013).

The patient’s antihypertensive medications and diuretic medications were held because he was scheduled for hemodialysis on the day of care. He tolerated his sevelamer well, no side effects noted. He was given his antidiabetic PO medication, sitagliptin, and no side effect was noted. He was given aspirin to prevent platelet aggregation. He tolerated this medication well too.

Diagnostic Tests and Procedures

Laboratory or test name	Normal range	Results on admission day	Results on the previous day assigned	Results for assigned day	Probable cause of abnormal and possible nursing responsibilities
Date:
WBC	4 – 10.8	13.6	14.2	8.5	Cellulitis; administer antibiotics
Hgb	13.5 – 16	7.6	7.5	7.3	ESRD; administer Epogen
Hct	38 - 45	22.5	21.1	21.5	ESRD; administer Epogen
PLT	160 - 400	236	371	407	Risk for blood clot
Glucose	70 -99	696	151	177	Diabetes; administer insulin
BUN	10 - 20	26	56	47	ESRD; dialysis
Creatinine	0.5- 1.25	6.7	12.33	10.95	ESRD; dialysis
Ca++	8.4 – 10.2	9.1	None applicable (N/A)	N/A	Normal level indicates the effectiveness of sevelamer
Na+	136 - 145	127	N/A	N/A	Low sodium level indicates inability of the kidney to reabsorb sodium. Monitor for hypotension and hypovolemia.
K+	3.5 - 5.0	4.6	N/A	N/A	Normal potassium level
ALT	0 -55	6	N/A	N/A	Normal level
AST	5 - 34	5	N/A	N/A	Normal level
Wound Culture	Light growth methicillin- resistant staphylococcus aureus (MRSA) found on

From the above laboratory results, it could be noted that his white blood cell count and glucose levels are both high; indicating that the patient’s body is fighting the infections and his blood glucose is high given that he has a history of diabetes mellitus. Blood glucose is expected to decrease after the administration of insulin. His hemoglobin and hematocrit are both low, because his kidneys are not able to release erythropoietin to initiate hematopoiesis. For this deviation, his primary care physician placed him on epogen to stimulate hematopoiesis. His platelet count is low because his kidneys cannot synthesis vitamin D to its active form. Vitamin D deficiency can lead to an increase in platelet count. BUN and creatinine are both high because his kidneys cannot excrete waste products from the breakdown of protein and muscles. The hemodialysis helps to remove waste products from his system. A wound culture was conducted and there was a light growth staphylococcus aureus found. For patients with wound infections, wound cultures are conducted to determine the presence of microorganisms at the site of infection (Pagana, Pagana, & Pagana, 2015).

Nursing Diagnosis

The nursing diagnoses suitable for this health deviation is excess fluid volume related to retention of sodium and water as evidenced by a decrease in urine output, hemoglobin and hematocrit to 7.3 and 21.5; and an increase  in BUN and creatinine to 47 to 10.95, respectively,  secondary to end stage renal disease (Ladwig, Ackley, & Makic, 2017). The goal is for the patient to keep the ideal body weight without excess fluid by discharge. Interventions includes limiting intake to an additional 500 to 600 milliliters on top of the previous day’s output. The second intervention is to explain to the patient the rationale for the fluid restriction and finally to identify potential sources of fluids increase.

The potential complication is hyperglycemia. The nurse will monitor blood glucose, for any change in level of consciousness and serum potassium level. The nurse will manage this complication by administering insulin as needed, educating patient about sick day rules, and educating the patient on insulin self-administration and the importance of hemodialysis to filter his blood. Finally, the nurse will minimize this complication with administration of insulin as needed, educating patient about consumption of low carb diet, and proper foot care (Ladwig, Ackley, & Makic, 2017).

                                                      References

Bigelow, A., & Freeland, B. (2017, March). Type 2 Diabetes care in the elderly. The Journal for Nurse Practitioners, 13(3), 181-186.

Chang, G.-H., Tsai, M.-S., Liu, C.-Y., Lin, M.-H., Tsai, Y.-T., Hsu, C.-M., & Yang, Y.-H. (2017). End-stage renal disease: a risk factor of deep neck infection - nationwide follow - up study in Taiwan. BMC Infectious diseases.

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's textbook of medical-surgical nursing (13th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Kossman, R., & Himmele, R. (2015). Overview of arteriovenous fistula. Advanced renal education program.

Ladwig, G. B., Ackley, B. J., & Makic, M. (2017). Mosby's guide to nursing diagnosis (5th ed.). St. Louis, Missouri, Canada: Elsevier.

Leifer, G., & Fleck, E. (2013). Growth and development across the lifespan: A health promotion focus (2nd ed.). Riverside, CA: Elsevier Saunders.

Norton, J. M., Newman, P. E., Romancito, G., Mahooty, S., Kuracina, T., & Narva, A. S. (2017). Improving outcomes for patients with chronic kidney. AJN, 117, 22 - 32.

Pagana, K. D., Pagana, T. J., & Pagana, T. N. (2015). Mosby's diagnostic & laboratory test reference (12 ed.). St. Louis, Missouri: Elsevier.

Stolic, R. (2012). Most Important chronic complications of arteriovenous fistula for hemodialysis. Medical Principles and Practice, 220 -228.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2013). Davis's drug guide for nurses (14th ed.). Philadelphia: F.A. Davis Company.