The Importance Of Evidence-Based Practice In Treating Acute Illness: A Case Study

Treating Patient in an Acute Care

Case Study of Patient with Acute Illness

Describe a essay about treating patient in an acute care?

Evidence-Based Practice (EBP) is the amalgamation of best available scientific studies and clinician’s expertise and patient’s conscience to provide the best possible outcomes for the patients. These criteria are fundamental components of the holistic nursing process (Kenneth et al., 1998). The present essay discusses the importance of EBP in the nursing approach for acute illnesses with the help of a case study which came across to me while serving in Accident and Emergency (A&E) department. I was appointed there to take care of the patients with respiratory problems which also helped me to enhance my knowledge in attending the patients with acute illness and strengthen my experience as a nurse.

The present discussion involves the case study of a 19-year old female patient (Wynaden et al., 2005) suffering from Down’s syndrome and acute dementia. However, the immediate reason for the admission was acute breathlessness. Patient’s history sheet revealed that she had undergone surgery for the correction of atrioventricular septum defect. She was also suffering from auditory impairment, vision disturbances and coeliac diseases. On first look, she appeared agitated and found difficulty in communicating with the nursing staff. She was also screaming her lungs out and didn’t cooperate with the nursing staff.

The available literature helps to correlate the clinical symptoms of the patient with her Down syndrome. Since, breathing is the process of exchanging gases through lungs and regulated by respiratory centres in brain, breathlessness can be correlated with patients of Down syndrome (Raven et al., 2007; Patton et al., 2009). Similarly, Atrioventricular Septal defect is a congenital heart deformity, strongly associated with and commonly found in individuals suffering from Down syndrome (Craig, 2006). Further, visual and auditory impairment and coeliac disease are frequent complaints in patient suffering with Down syndrome (Lott & Dierssen, 2010; Shott, 2006; Figueroa et al., 2003). Her inappropriate speech and language characteristics and strange behaviour are also closely associated with Down syndrome (Martin et al., 2009).

After admission, the attending nurse started the comprehensive assessment of vitals and ensured the respiration by using Airway, Breathing, Circulation, Disability & Exposure (ABCDE) tool. Usually, ABCDE tool is used by physicians to handle emergency cases and it has been found to provide better results by allowing the doctors to concentrate on the most serious life-threatening health disorders (Wardrope & Mackenzie, 2004). This approach provides an immediate evaluation and action plan for the health care workers and inspires them to offer efficient treatment along with buying precious time to make decisions on the final diagnosis and treatment plan during emergency cases (Dent & Carey 2006). At the beginning of the assessment, the AVPU (Alert Response to Voice, Response to Pain and Unresponsiveness) scale was employed as a part of the review procedure to assess the level of consciousness of the patient. She was alert and responsive as she reacted well to the verbal cues and appropriately conveyed that she was in pain (Cormac, 2012).

Assessment of Vitals for Patient

The next phase of protocol involved the evaluation of the respiratory functioning of the patient. The prime goal of this stage is to assess the risk of any life-threatening condition related to respiration. The patient was breathing very fast which was physically identified by the active rise and fall of her chest. Consequently, respiration rate of the patient was 30 breaths per minute (BPM) which indicates tachypnea (Bull, 2011). Abnormal respiration rate can be directly associated with pain, lung disease, pneumonia, anxiety or congestive heart failure (Spicer, 1984; Myers & Pueschel, 1991; Bone et al., 1992; Ko et al., 2003; Bloemers et al., 2007).

Further, the oxygen saturation level (SpO2) was measured with the pulse oximeter (Marcus et al., 1991), a non-invasive technique used to measure arterial saturation level with the help of a sensor. It measures the percentage of oxygen in the blood and its corresponding haemoglobin (De Villota et al., 1981).  Anna’s oxygen level was 91 %, which was below the normal range (95 to 100 %) (Marcus et al., 1991). Observation suggests that Anna was suffering from mild hypoxia which implies that there was an insufficient amount of oxygen in the blood. Hypoxia may lead to anxiety, chest infection and lung problems (Marteau et al., 1988; McDowell & Craven, 2011). A non-breath face mask was provided to improve her oxygenation (Garcia et al., 2005).

Now the nursing team should evaluate the pulse rate which is the second important vital as per the ABCDE protocol. Anna’s pulse rate was 80 BPM, which is slight faster than the homeostatic level (60 – 90 BPM). Heart rate faster than normal is suggestive of tachycardia which also implicate rise in blood pressure (BP) (Saenz, 1999). Further, the blood glucose level of Anna was taken as a part of the routine clinical assessment procedures. The blood glucose level was 4.8 mm/L, which falls within the normal range of 3.5 – 5.5 mm/l.  So, the nursing team didn’t add any interventions for blood glucose level management (Engelgau et al., 2000; Hill et al., 2011).

As per ABCDE protocol, attending nurse opened the windows of the ward room for exposure assessment and treatment. Also, open environment helped to calm her and make her feel relaxed. Anna’s body temperature was normal, and the nursing team didn’t found any mark of body injuries. Further in the process, the weight of the patient was measured. Anna’s BMI was 35 which indicate that she is suffering from severe obesity, which can also cause gastrointestinal disorder in patients with Down syndrome. Anna was reported to be suffering from severe constipation which can lead to the development of agitation, rapid pulse, fever, confusion, dehydration and rapid breathing (Cohen, 2003; Holmes, 2014). Constipation as described earlier is not having enough bowel movements (less than three times a week) was also found to be associated with her coeliac disease (Bonamico et al., 2001).

Nursing Intervention for the Patient

As per the National Early Warning Score (NEWS), Anna scored 7 and fell under a high-risk patient category (Hill, 2012). Nurses often employ the SBAR method for the exchange of significant information that calls for instant consideration with the medical practitioners to enhance the patient’s safety and well-being (Boutilier, 2007).

Primarily, nursing staff tried to deal with the anxiety levels of the patient. Anxiety is a type of feeling of uneasiness caused by any fear (May, 1996), which may originate from the stimulation of the sympathetic nervous system and the hypothalamic pituitary adrenal (HPA) axis. Anxiety may induce complications like an increase in the rate of respiration and cardiovascular excitation (Davis, 1992). As per the ethical guidelines, each patient admitted to the hospital, frequently feels that they are in a safe place and deserve to receive rapid and efficient medical treatment (Armitage et al., 2007). That is why, the nursing staff was trying to assure and console Anna, with the motive of reducing her level of agitation and excitement (Webster, 1999; Jevon et al., 2012). Anxiety is a highly individualised condition which varies in both the physical and psychological response to the inner and external life events (Davis & Thaut, 1989). The nursing staff should continuously inform Anna that they are attending to all of her requirements efficiently and without any interruption. It seemed to decrease her anxieties and help her to relax. It is often critical to keep the patients informed at all times since it permits the patient to be part of all the decisions about his or her treatment (Coulter et al., 2008; Vahdat et al., 2014). It is of utmost importance that the nursing team must persuade the nurses to stay calm, composed, gentle, comforting and offering support to the patient in overcoming their anxieties and fears (Brett et al., 2014).  The presence of a nurse, their concerns regarding the patient’s health and other verbal and healing touch methods can assure the patient that they are not by themselves in the current situation. The healing touch technique may be the most constructive and functional nursing intervention available that can effectively decrease a patient’s anxiety. Accompanying the patient at all times, speak softly and clearly and facing the patient in an attempt to let them read the lips facilitate the better understanding (Hart et al., 2011; Richmond et al., 2012). The active involvement of the health care provider is essential in the nursing field as it facilitates the adherence of patients to the treatment plan resulting in the better outcomes (Armitage et al., 2007).

Importance of Calming the Patient

During holistic care, the presence of an attendant is always an added advantage for medical team. In the present case, fortunately, Anna’s brother was able to present with the appropriate details which helped nurses to manage the condition of the patient. His presence provided a positive sense of protection and helped her to decrease the levels of anger and agitation which consequently improved the breathing.  As per the protocol, nurses must exploit simple terminologies to make sure that the patient can understand completely, and nurse/patient dialogue will become meaningful (Bramhall, 2014; Kourkouta & Papathanasiou, 2014).  Effective communication is the spirit of all human interactions and without which individuals will not be able to communicate with the people around them or share their thoughts or concerns (Vertino, 2014). An effective interaction between the nurses and the patient requires an understanding of the patient and their experiences (McCabe, 2004). Nurses should espouse a body language that is friendly and non-threatening which can help in comforting the patient because it is crucial to have an agreement between the verbal and non-verbal communication in tense situations (Taylor, 1992; Kourkouta & Papathanasiou, 2014). Nurses should permit or support the patient’s personal expression of pain and discomfort since sometimes it would be helpful in reducing the anxiety by talking or expressing one’s feelings (Iezzoni et al., 2006). Anna and similar high-risk patients need a serious attention and effective communication to ensure better outcomes (Morse, 1991). To control Anna’s anxiety problem, nurses take up a compassionate stand by providing a socio-psychological support (Laschinger et al., 2005) and increasing the positive self-talk and reducing the negative self-talk in a conversation (Kendall et al., 1989; Ozbay et al., 2007). Doctors and nurses should attempt to build a relationship with the patient who is experiencing generalised anxiety disorder. The conversations with the patient must be carried out in a safe environment to ensure the confidentiality, privacy and dignity of a patient (Fisher et al., 2008).

After releasing the anxiety, nursing staff take charge to relieve the respiratory exertion to manage the hypoxia. Anna was encountering breathlessness which usually occurs when the requirement for oxygen surpasses her assumed lung capacity. The increase in the pressure of carbon dioxide in the arterial blood stream activates the respiratory centre in the brain to augments the rate and depth of breathing which ultimately cause dyspnoea. (Wood et al., 1977; Hunter, 2008). As per the National Institute for Health and Clinical Excellence 2007, when a patient admitted to the hospital show an increased rate of respiration of >30 BPM and an oxygen saturation of < 92 %, it is treated as an emergency case (NIfHaC, 2007). The nurse must also tend to the breathlessness, which is a premature sign of acute illness (Armitage et al., 2007). To improve the breathing response, the nursing team employed an SBAR tool to raise concern (Pronk, 2008; Tews et al., 2012). Nurses changed the position of the patient by adjusting pillows to elevate her head and chest, so as to ensure the comparative easier breathing. The change in position has dual action as it permitted her chest walls to move and expand freely (Harris & Crawford, 2008) and enhances oxygen distribution throughout the lungs which ultimately improves breathing in patients (Oksenberg et al., 2006). Evidence suggested that when a person is lying flat, he/she will experience difficulty in breathing. In that case, slight elevation of their head and chest from the surface has been employed to treat breathing difficulties. Furthermore, the individuals with breathing difficulties might be benefitted when they are sitting in a Semi-Fowler’s position (30-degree elevation of the upper body) (Yeaw, 1992; Younes, 2003; Chung et al., 2008). So, this is one of the best ways of managing acute breathlessness (Dean, 1985). It is also crucial to know that the upright sitting position permits breathing without the over-bending of the stomach which can confine the diaphragm (Moosavi & Booth, 2011).

Conclusion

Oxygen saturation below the 92% warrants the administration of oxygen therapy (Kallstrom, 2002). Oxygen therapy involves the use of supplemental oxygen which is frequently delivered directly to the lungs (Creed et al., 2010; Dougherty & Lister, 2015). The nurses firstly need to administer 5-10 litres of oxygen by a face mask to attain the saturation of 94-98% (Bradley et al., 2008; Welham et al., 2010). It is a frequent management technique for the patients with acute breathlessness admitted to the hospital (Dougherty & Lister, 2015). But, a large quantity of oxygen can cause nose bleed, drying of nasal passages and discomfort to the patients. Therefore, the use of humidified air helps to keep delicate tissues that line the nasal cavity moist. To achieve the required oxygen saturation and saturation range, the physicians must use appropriate equipment and the entire procedure must be recorded (O’Driscoll et al., 2008).

In the process, Anna’s oxygenation was done by a non-rebreather oxygen mask. Further, nurses encouraged her to drink cold fluids for recovering the hydration state and mobilize the secretions (Ross & Alexander, 2001). The fan was turned on to decrease the body temperature which also helps to calm the patient (Kehl, 2004; Moosavi, & Booth, 2011).On the contrary, a cannulation is an alternative option when patients are not able to take sufficient amount of food orally (Cole, 2008). If a patient cannot able to drink then, the nurse would introduce a cannula into her body to administer prescribed fluids. Any change in the vital signs of the patient should be recorded and treated.

Nurses also explained all the procedures to Anna, to reduce her anxiety induced breathlessness. Nurses mediate the interactions between Anna and the respiratory physiotherapist who is helping her with breathing exercises. Anna was encouraged to lose weight to control her BMI. Respiratory functions are significantly affected by obesity (Ray et al., 1983). In addition to this, the residual capacity is decreased by the presence of adipose tissue around the chest wall (Salome et al., 2013).

Further, nurses administered medications by using a nebuliser. The nebulizer mask vaporizes the liquid medication into fine vapour which is inhaled by the patient. It gives fast relief in patients with acute breathlessness (Hilliard & Kenneth, 1996). An electrocardiogram (ECG) assessment of Anna was done to rule out any cardiac-pulmonary involvement.

This article has emphasized on the requirement of a complete and efficient assessment plan for working with the patients suffering from acute breathing difficulties. It is of utmost importance to clearly understand the patient’s vital signs as these data can influence in making the decision of diagnosis and treatment planning. The collection of the detailed medical history of the patient by nursing staff is an important aspect of diagnosis and designing the treatment protocol for the patient. On concluding remarks, we can say that the collective work of the patient’s family and the medical team is of foremost importance in making any treatment plan successful. 

References

Armitage, M., Eddleston, J. and Stokes, T., 2007. Recognising and responding to acute illness in adults in hospital: summary of NICE guidance. British Medical Journal, 335(7613), pp. 258-259.

Bloemers, B.L., van Furth, A.M., Weijerman, M.E., Gemke, R.J., Broers, C.J., Van den Ende, K., Kimpen, J.L., Strengers, J.L. and Bont, L.J., 2007. Down syndrome: a novel risk factor for respiratory syncytial virus bronchiolitis—a prospective birth-cohort study. Pediatrics, 120(4), pp. e1076-e1081.

Bonamico, M., Mariani, P., Danesi, H.M., Crisogianni, M., Failla, P., Gemme, G., Quartino, A.R., Giannotti, A., Castro, M., Balli, F. and Lecora, M., 2001. Prevalence and clinical picture of celiac disease in Italian Down syndrome patients: a multicenter study. Journal of Pediatric Gastroenterology & Nutrition, 33(2), pp. 139-143.

Bone, R.C., Balk, R.A., Cerra, F.B., Dellinger, R.P., Fein, A.M., Knaus, W.A., Schein, R.M. and Sibbald, W.J., 1992. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest Journal, 101(6), pp. 1644-1655.

Booth, S., 2013. Science supporting the art of medicine: improving the management of breathlessness. Palliative Medicine, 27(6), pp. 483-485.

Boutilier, S., 2007. Leaving critical care: facilitating a smooth transition. Dimensions of Critical Care Nursing, 26(4), pp. 137-142.

Bradley, B., Branley, H.M. and Egan, J.J., 2008. Guideline for emergency oxygen use in adult patients. Thorax, 63(5), pp. 1-58.

Bramhall, E., 2014. Effective communication skills in nursing practice. Nursing Standard, 29(14), pp. 53-59.

Brett, J., Staniszewska, S., Mockford, C., Herronâ€ÂMarx, S., Hughes, J., Tysall, C. and Suleman, R., 2014. Mapping the impact of patient and public involvement on health and social care research: a systematic review. Health Expectations, 17(5), pp. 637-650.

Bull, M.J., 2011. Health supervision for children with Down syndrome. Pediatrics, 128(2), pp. 393-406.

Chung, S.A., Yuan, H. and Chung, F., 2008. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesthesia & Analgesia, 107(5), pp. 1543-1563.

Cohen, W.I., 2003. Health care guidelines for individuals with Down Syndrome—1999 revision. Down Syndrome, pp. 237.

Cole, E., 2008. Cannulation and venepuncture. Blood, 16(10.8), pp. 9-14.

Cormac, I., 2012. Essentials of Physical Health in Psychiatry. RCPsych Publications.

Coulter, A., Parsons, S. and Askham, J., 2008. Where are the patients in decision-making about their own care. World Health Organization.

Craig, B., 2006. Atrioventricular septal defect: from fetus to adult. Heart, 92(12), pp. 1879-1885.

Creed, F. and Spiers, C. eds., 2010. Care of the acutely ill adult: an essential guide for nurses. OUP Oxford.

Davis, M., 1992. The role of the amygdala in fear and anxiety. Annual Review of Neuroscience, 15(1), pp. 353-375.

Davis, W.B. and Thaut, M.H., 1989. The influence of preferred relaxing music on measures of state anxiety, relaxation, and physiological responses. Journal of Music Therapy, 26(4), pp. 168-187.

de Rubens Figueroa, J., del Pozzo Magaña, B., Hach, J.L.P., Jiménez, C.C. and Urbina, R.C., 2003. Heart malformations in children with Down syndrome. Revista Española de Cardiología, 56(09), pp. 894-899.

De Villota, E.D., Carmona, M.G., Rubio, J.J. and de Andrés, S.R., 1981. Equality of the in vivo and in vitro oxygen-binding capacity of haemoglobin in patients with severe respiratory disease. British Journal of Anaesthesia, 53(12), pp. 1325-1328.

Dean, E., 1985. Effect of body position on pulmonary function. Physical Therapy, 65(5), pp. 613-618.

Dent, K.M. and Carey, J.C., 2006, August. Breaking difficult news in a newborn setting: Down syndrome as a paradigm. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics, Vol. 142, No. 3, pp. 173-179.

Dougherty, L. and Lister, S., 2015. The royal marsden manual of clinical nursing procedures. John Wiley & Sons.

Engelgau, M.M., Narayan, K.M. and Herman, W.H., 2000. Screening for type 2 diabetes. Diabetes Care, 23(10), pp. 1563-1580.

Fisher, C.B. and Oransky, M., 2008. Informed consent to psychotherapy: Protecting the dignity and respecting the autonomy of patients. Journal of Clinical Psychology, 64(5), pp. 576-588.

Garcia, J.A., Gardner, D., Vines, D., Shelledy, D., Wettstein, R. and Peters, J., 2005. The oxygen concentrations delivered by different oxygen therapy systems. Chest, 128(4), pp. 389S-389S.

Harris, H. and Crawford, A. 2008. COPD. Help your patients breathe easier. RN, 71(1), pp. 21-6.

Hart, L.K., Freel, M.I., Haylock, P.J. and Lutgendorf, S.K., 2011. The use of healing touch in integrative oncology. Clinical Journal of Oncology Nursing, 15(5), pp. 519.

Hill, K., 2012. National Early Warning Score. Nursing in Critical Care, 17(6), pp. 318-318.

Hill, N.R., Oliver, N.S., Choudhary, P., Levy, J.C., Hindmarsh, P. and Matthews, D.R., 2011. Normal reference range for mean tissue glucose and glycemic variability derived from continuous glucose monitoring for subjects without diabetes in different ethnic groups. Diabetes Technology & Therapeutics, 13(9), pp. 921-928.

Hilliard, K.R., Hilliard and Kenneth R., 1996. Oxygen mask with nebulizer. U.S. Patent 5,586,551.

Holmes, G., 2014. Gastrointestinal disorders in Down syndrome. Gastroenterology and Hepatology from Bed to Bench, 7(1), pp. 6.

Hunter, J., 2008. Chest drain removal. Nursing Standard, 22(45), pp. 35-38.

Iezzoni, L.I., Ramanan, R.A. and Lee, S., 2006. Teaching medical students about communicating with patients with major mental illness. Journal of General Internal Medicine, 21(10), pp. 1112-1115.

Jevon, P., Ewens, B. and Pooni, J.S., 2012. Monitoring the critically ill patient. John Wiley & Sons.

Kallstrom, T.J., 2002. AARC Clinical Practice Guideline: oxygen therapy for adults in the acute care facility–2002 revision & update. Respiratory Care, 47(6), pp. 717-720.

Kehl, K.A., 2004. Treatment of terminal restlessness: a review of the evidence. Journal of Pain & Palliative Care Pharmacotherapy, 18(1), pp. 5-30.

Kendall, P.C., Howard, B.L. and Hays, R.C., 1989. Self-referent speech and psychopathology: The balance of positive and negative thinking. Cognitive Therapy and Research, 13(6), pp. 583-598.

Kenneth N. Anderson, ed. (1998). Mosby’s medical dictionary : illustrated in full color throughout (5th revised ed.). St. Louis: Mosby. ISBN 0815146310.

Kevin T. Patton, Gary A. Thibodeau (2009). Anatomy & Physiology (7 ed.). Mosby. ISBN 0-323-05532-X.

Ko, S., Goldstein, D.H. and VanDenKerkhof, E.G., 2003. Definitions of “respiratory depression” with intrathecal morphine postoperative analgesia: a review of the literature. Canadian Journal of Anaesthesia, 50(7), pp. 679-688.

Kourkouta, L. and Papathanasiou, I.V., 2014. Communication in nursing practice. Materia Socio-medica, 26(1), pp. 65.

Gary E. Martin, Jessica Klusek, Bruno Estigarribia and Joanne E. Roberts. 2009. Language Characteristics of Individuals with Down Syndrome. Topics in Lanugage Disorders. 29(2), pp. 112–132.

Laschinger, H.S., Hall, L.M., Pedersen, C. and Almost, J., 2005. A psychometric analysis of the patient satisfaction with nursing care quality questionnaire: an actionable approach to measuring patient satisfaction. Journal of Nursing Care Quality, 20(3), pp. 220-230.

Lott, I.T. and Dierssen, M., 2010. Cognitive deficits and associated neurological complications in individuals with Down’s syndrome. The Lancet Neurology, 9(6), pp. 623-633.

Marcus, C.L., Keens, T.G., Bautista, D.B., von Pechmann, W.S. and Ward, S.L.D., 1991. Obstructive sleep apnea in children with Down syndrome. Pediatrics, 88(1), pp. 132-139.

Marteau, T.M., Kidd, J., Cook, R., Johnston, M., Michie, S., Shaw, R.W. and Slack, J., 1988. Screening for Down’s syndrome. British Medical Journal, 297(6661), pp. 1469-1469.

May, R., 1996. The meaning of anxiety. WW Norton & Company.

McCabe, C., 2004. Nurse–patient communication: an exploration of patients’ experiences. Journal of Clinical Nursing, 13(1), pp. 41-49.

McDowell, K.M. and Craven, D.I., 2011. Pulmonary complications of Down syndrome during childhood. Journal of Pediatrics, 158(2), pp. 319-325.

Moosavi, S.H. and Booth, S., 2011. Pathophysiology of breathlessness. The Cambridge Breathlessness Manual.

Morse, J.M., 1991. Negotiating commitment and involvement in the nurse – patient relationship. Journal of Advanced Nursing, 16(4), pp. 455-468.

Myers, B.A. and Pueschel, S.M., 1991. Psychiatric disorders in persons with Down syndrome. Journal of Nervous and Mental Disease, 179(10), pp. 609-613.

NIfHaC, E., 2007. NICE clinical guideline 50 Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital. London: National Institute for Health and Clinical Excellence.

O’Driscoll, B.R., Howard, L.S. and Davison, A.G., British Thoracic Society (2008) BTS guideline for emergency oxygen use in adult patients. Thorax, 63, pp. 1-73.

Oksenberg, A., Silverberg, D., Offenbach, D. and Arons, E., 2006. Positional Therapy for Obstructive Sleep Apnea Patients: A 6-Month Follow-Up Study. The Laryngoscope, 116(11), pp. 1995-2000.

Ozbay, F., Johnson, D.C., Dimoulas, E., Morgan, C.A., Charney, D. and Southwick, S., 2007. Social support and resilience to stress. Psychiatry, 4(5), pp. 35-40.

Peter R., George J., Kenneth M., Jonathan L., Susan S., 2007. “The capture of oxygen: Respiration”. Biology (8 ed.). McGraw-Hill Science/Engineering/Math. ISBN 0-07-322739-0.

Pronk, N., 2008. Situation-Background-Assessment-Recommendation: A Practitioner’s Communication Tool. ACSM’s Health & Fitness Journal, 12(5), pp. 42-43.

Ray, C.S., Sue, D.Y., Bray, G., Hansen, J.E. and Wasserman, K., 1983. Effects of Obesity on Respiratory Function 1–3. American Review of Respiratory Disease, 128(3), pp. 501-506.

Richmond, J.S., Berlin, J.S., Fishkind, A.B., Holloman, G.H., Zeller, S.L., Wilson, M.P., Rifai, M.A. and Ng, A.T., 2012. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1), pp. 17-25.

Robert F. Schmidt, William D. Willis, ed. (2007). Encyclopedia of pain. Berlin: Springer. p. Acute Pain, Subacute Pain and Chronic Pain (Chapter.). ISBN 978-3-540-29805-2.

Ross, D.D. and Alexander, C.S., 2001. Management of common symptoms in terminally ill patients: Part II. Constipation, delirium and dyspnea. American Family Physician, 64(6), pp. 1019-1026.

Saenz, R.B., 1999. Primary care of infants and young children with Down syndrome. American Family Physician, 59, pp. 381-400.

Salome, C.M., King, G.G. and Berend, N., 2013. Effects of Obesity on Lung Function. In Obesity and Lung Disease, pp. 1-20. Humana Press.

Shott, S.R., 2006. Down syndrome: common otolaryngologic manifestations. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics, Vol. 142, No. 3, pp. 131-140.

Spicer, R.L., 1984. Cardiovascular disease in Down syndrome. Pediatric Clinics of North America, 31(6), pp. 1331-1343.

Taylor, M., 1992. The nurse-patient relationship. Senior Nurse, 13(5), pp. 14-18.

Tews, M.C., Liu, J.M. and Treat, R., 2012. Situation-Background-Assessment-Recommendation (SBAR) and Emergency Medicine Residents’ Learning of Case Presentation Skills. Journal of Graduate Medical Education, 4(3), pp. 370-373.

Vahdat, S., Hamzehgardeshi, L., Hessam, S. and Hamzehgardeshi, Z., 2014. Patient involvement in health care decision making: a review. Iranian Red Crescent Medical Journal, 16(1), e12454.

Vertino, K., 2014. Effective Interpersonal Communication: A Practical Guide to Improve Your Life. OJIN: The Online Journal of Issues in Nursing, 19(3), 1.

Wardrope, J. and MacKenzie, R., 2008. The system of assessment and care of the primary survey positive patient. Community Emergency Medicine, p.15.

Webster, N.R., 1999. Monitoring the critically ill patient. Journal of the Royal College of Surgeons of Edinburgh, 44(6), pp. 386-393.

Welham, S.A., O’Driscoll, B.R., Howard, L.S., Davison, A.G. and Edwards, S., 2010. P50–BTS Guideline for Emergency Oxygen Use in Adult Patients. Otolaryngology–Head and Neck Surgery, 143(1), pp. 103-104.

Wood, S.C., Johansen, K. and Gatz, R.N., 1977. Pulmonary blood flow, ventilation/perfusion ratio, and oxygen transport in a varanid lizard. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 233(3), pp. R89-R93.

Wright, J.H. and Davis, D., 1994. The therapeutic relationship in cognitive-behavioral therapy: Patient perceptions and therapist responses. Cognitive & Behavioral Practice, 1(1), pp. 25-45.

Wynaden, D. and Orb, A., 2005. Impact of patient confidentiality on carers of people who have a mental disorder. International Journal of Mental Health Nnursing, 14(3), pp. 166-171.

Yeaw, E.M., 1992. CE Credit: How Position Affects Oxygenation Good Lung down? The American Journal of Nursing, pp. 27-32.

Younes, M., 2003. Contributions of upper airway mechanics and control mechanisms to severity of obstructive apnea. American Journal of Respiratory & Critical Care Medicine, 168(6), pp. 645-658.