PHILIPPINE CHRISTIAN UNIVERSITY

Mary Johnston College of Nursing

415 Morga St., Tondo Manila

In Partial Fulfillment of the requirements

In the Medicine Ward Duty

Case study
On

Unstable Angina

Submitted by:
Ms. Cayas, Jennylyn
Ms. Moleta, Hazel Joyce

BSN-III, RLE Group 2

Submitted to:
Ms. Ma. Nicoleta M. Dizon

I. ABSTRACT, IDENTIFICATION and INTRODUCTION

Unstable angina generally represents a condition more serious than
chronic stable angina pectoris. The terms unstable indicates that the patient is in a
changing situation, which may be a prelude to an acute myocardial or a return to more
stable pattern. ( by E.P Dutton, HEARTBOOK, The American Association, USA, New
York)
Chest pain is the most common symptom of cardiovascular disease.
Angina pains, while possibly severe, are usually temporary, occurring after physical
exertion, during emotion stress, or after heavy meals. The last few decades have
witnessed remarkable advances in the understanding of coronary heart disease, and yet
the disease still presents a very great challenge to the medical profession.
The purpose of this study is to gain knowledge and to increase our competency in
assessment especially in cardiovascular part and also in rendering nursing care that are
appropriate based on the clients case.
In our case, a 69 year old, a lawyer is brought to the Mary Johnston
Hospital due to loss of consciousness. He has been diagnosed to have hypertensive
cardiovascular disease. His initial BP: 160/100mmHg. The patient has a type two
diabetes. He is fond of eating high fat and high salt foods, smoker and alcoholic drinker.
He had also hypertensive history within the family. Problem that was identified were the
ff: chest pain, having productive cough, activity intolerance, electrolyte imbalances and
diet modification.

II. CASE REPORT

Demographic Data

Name: Santos, E. A.
Age: 69 years old
Birthday: September 23, 1942
Gender: Male
Status: Widow
Religion: Roman Catholic
Nationality: Filipino
Nursing History

History of Present Illness

The client was seeing in the comfort room by his relatives with loss of consciousness but
can still respond by nodding. He experienced pain in the chest. He was immediately
brought to hospital. His BP was 160/100 mmHg and known to have HCVD. He was
known to have CAP. He was then admitted to Medical ICU for 11 days and then
transferred to Medicine Ward.

Past Medical History

The client is Diabetic but he doesnt know since when. He was admitted to MICU last
April or May because of the same condition. The client has Insomnia.

Family History
The clients Siblings are Hypertensive.

Personal-Social History

- Retired Lawyer but still accepting easy to handle cases.

- Smoker 30packs/year
- Alcoholic Drinker 2L/day

Gordons Functional Health Pattern

Health Perception
-

Ok naman ako, gusto ko na nga umuwi as stated by patient

Nutrition-Metabolic
-

Di siya mahilig sa gulay, kadalasan mga baboy as stated by son

Di siya kumakain ng Isda, pero nkain siya ng satdinas as stated by son
Tuwing kumakain lang siya nainom ng tubig, di siya mahilig as stated by son
Nainom siya ng kape sa umaga as stated by son

Elimination
-

Araw-araw naman siya dumudumi as stated by son

Wala naman siyang sinasabi na masakit ang pag-ihi niya as stated by son
With Foley Catheter connected to CDU

Activity-Rest
-

Madalas lang siya sa bahay, mahilig manuod ng T.V. as stated by son

Mahilig yan magbasabasa ng Dyaryo -as stated by son

Sleep-Rest
-

May Insomnia siya eh, di siya nakakatulog kapag di siya nakakainom ng alak

as stated by son
Pampatulog na niya ang alak as stated by son
Cognitive Perceptual
-

Di malabo mata niya, sa dyaryo nga nababasa niya pa eh as stated by son

Ok din naman pandinig niya as stated by son

Self-Perception

Ok lang ako, magaling na ko as stated by son

Roles and Relationship

-

Sa bahay tatlo lang kami magkakasama, siya, ako at yung kapatid ko na isa

as stated by son
Sexuality-Reproductive
-

Tatlo kaming anak lahat yung isa iba yung nanay as stated by son
Si mama namatay dahil sa stroke as stated by son

Coping Stress Tolerance

-

Naiistress kapag di nakakainom as stated by patient

Dapat makainom ako ng alak as stated by patient

Values and Belief

-

Di na nagsisimba yan si papa, sa bahay lang palagi as stated by son

Di naman nakakalimot magdasal yan as stated by son

Physical Examination

Head

Normocephalic
No lesion
No mass

Hair

Grayish in color
Dry hair

Eyes

Ears

Symmetrical
Dry eyes noted
Pinkish conjunctivae

No lesion
Symmetrical
No discharge

Nose

Nasal septum Intact

No mucus

Mouth

Incomplete set of teeth

Dry lips
Pinkish oral mucosa

Chest

Use of respiratory muscle

No lesion
No mass noted

Abdomen

Soft and flabby

No lesion
No mass

Skin

Dry and sagging skin

Fair complexion

Extremities

Symmetrical
Complete set of fingers and toes
Can do ROM but with assistance

Laboratory/Diagnostics (from oldest to latest)

February 25, 2012
Na

137 mmol/L

135-145

normal

2.3 mmol/L

3.6-5.0

low

March 02, 2012

Na

133.9 mmol/L

135-145

low

3.55 mmol/L

3.6-5.0

low

Interpretation

The client has a low sodium and potassium. The client is taking a medication of

diuretics and the Na and K was been excreted. This indicates that there is an inadequate
Na and K in the body. As a nurse, encourage the client to eat foods rich in sodium and
potassium like seafood, banana and potatoes.

ECG
February 23, 2012
Interpretation- Atrial Tachycardia, Normal Axis, Left Atrial Abnormality
February 25, 2012
Interpretation- Atrial Tachycardia, Normal Axis, Poor R wave progression.
Drug Study
1.

Furosemide
Loop diuretics
Inhibits sodium and chloride reabsorption at the proximal tubules, distal tubules

and ascending loop of henle leading to excretion of water together with Na, Cl and K.
Diuretic, Anti-hypertensive.

This is given because the client has a Foley catheter and his output was being
measured. The fluids in the body must be secreted to prevent fluid excess in the body
that can cause hypertension and the worst is heart congestion.
2.

Clopidogrel
Anti-coagulant, Anti-platelets
Blocks ADP receptors, which prevents fibrinogen binding at the site and thereby

reduce the possibility of platelet and aggregation.

The client is hypertensive and known to have Diabetes Mellitus. This drug is

given to prevent thrombus or clot formation in the vessels because patients with
hypertension and DM have the higher risk to have it.
3.

Enoxaparine
Anti-coagulant
Stimulates both Alpha and Beta receptors within sympathetic nervous system

that relaxes bronchial smooth muscle.

The client is hypertensive and known to have Diabetes Mellitus. This drug is
given to prevent thrombus or clot formation in the vessels because patients with
hypertension and DM have the higher risk to have it.
4.

Amiodarone
Anti-arrhythmics
Blocks sodium channels at rapid pacing frequencies, prolonging myocardial cell

action potential and refractory period.

This drug is given to normalize the heart rhythm because the client experienced
increased in heart contraction.
5.

Pantoprazole
Proton pump inhibitor
Inhibits both basal and stimulated gastric acid secretion by suppressing the final

step in acid production, through the inhibition of proton pump by binding to and inhibiting
hydrogen-potassium adenosine-triphospate the enzyme system located at the secretory
surface of the gastric parietal cell.

This drug contributes in the action of clopidogrel. It is also given because the
client eats in little amount, this is given to prevent the increase in acid production that
can cause ulceration.
6.

Kalium durule
Supplements for hypokalemia
The client has a decrease in Potassium. This is given to supply the inadequacy

of potassium in the body.

III. DISCUSSION
Literature
Scott Wright, R. et al.
(2011). Guidelines for
the management of
patients with unstable
angina/ non ST

Findings

Clo
pidogrel
in
combinati
on with

Claim
1.
T
here
are
drugs
that

Evidence
o
Data
from a
number of
observation
al studies

elevation myocardial
infarction.
http://circ.ahajournals.
org/content/
123/18/2022.full#sec7

ASA has
been
shown to
reduce
recurrent
coronary
events in
post
hospitaliz
ed ACS.

Pro
ton pump
inhibitor
medicatio
ns have
been
found to
interfere
with the
metabolis
m of
clopidogre
l.

Dia
betes as
well as
the often
concurren
t
comorbidi
ty of CKD,
is not only
a highrisk factor
but also
benefits
from an
invasive
approach.

can
preven
t
having
throm
bus or
plaque
format
ion.

have
demonstrate
d an
association
between an
increased
risk of
adverse
cardiovascul
ar events
and the
presence of
1 of the
nonfunctioni
ng
alleles and
are well
delineated
in the
ACCF/AHA
Clopidogrel
Clinical Alert
(Scott
Wright, R. et
al. 2011).
o
Two
novel
findings
have
emerged
from this
analysis.
First, in
contrast to
the studies,
clopidogrel
had the
same
relative
benefit
across all of
the risk
strata. The
relative
benefit was
20% in the
low-risk,
intermediate
-risk, and
high-risk

Rabin, E. & Bullard, M.

(1999). Chest pain
observation units for
patients with unstable
angina.
http://www.cjemonline.ca/v1/n1/ p39

An
Emergenc
y
Departme
nt Chest
Pain Unit
is safe,
effective

2.
T
here
are
diseas
es that
can be
a risk
factor

patients. It
is worth
noting that
because the
baseline risk
is higher,
the absolute
benefit is
greatest in
the highestrisk
patients.
The second
novel finding
of this
analysis is
that there
was a
statistically
significant
benefit of
clopidogrel
plus aspirin
over aspirin
alone in the
low-risk
patients.
(Cannon, C.
P. 2005)
o
Antith
rombotic
therapy is
designed to
stop platelet
aggregation
and interfere
with the
coagulation
process.
(Matura, L.
A. et al.
2003)
o
Diabe
tes is
another
characteristi
c associated
with high
risk for
adverse

and
economic
al means
of
providing
appropriat
e care to
patients
with
unstable
angina at
intermedi
ate risk
for
cardiovas
cular
events.

of
unstab
le
angina
.

outcomes
after
UA/NSTEMI.
(Scott
Wright, R. et
al. 2011)
o
The
observation
al data with
regard to
patients
with mild to
severe CKD
also support
the
recognition
that CKD is
an
underapprec
iated highrisk
characteristi
c in the
UA/NSTEMI
population
(Scott
Wright, R. et
al. 2011)
o
Out of
all patients
35.8% were
female, 30%
were
diabetics
(Duration
13.4 8.7
years), 42%
were smoker
and 91%
were
hypertensiv
e (Abbasi,
M. et el.
2006)
o
Threevessel
disease was
diagnosed in
42% of
diabetic and

31% of
nondiabetic
patients. In
a
multivariate
analysis
including
the extent of
CAD,
diabetes
remained a
strong
independent
predictor of
the
combined
end point.
(Norhammar
, A. et al.
2004)
o
Data
were
collected on
1046 ACS
patients of
whom 170
(16%) had a
prior
diagnosis of
DM. Based
on the rate
of
recruitment
and the
population
covered in
the study,
about
21,000
patients
with DM will
be admitted
with non-ST
elevation
ACS each
year in the
UK. (Bakhai,
A. et al.
2005)
o
Calcifi

Collet, J. P. et al.
(2002). Enoxaparin in
unstable angina
patients who would
have been excluded
from randomized
pivotal trials.
http://www.sciencedir
ect.com/
science/article/pii/
S0735109702026645

Eno
xaparin
with dose
adjustme
nt to
creatinine
clearance
provides
adequate
anti-Xa
and no
excess of
bleeding.

3.
T
here
are
ways
to
reduce
mortal
ity in
patien
t with
ACS.

ed plaques
in the DM
group were
significantly
greater than
those in the
non-DM
group
(42.9% vs.
23.1%; p =
0.03). (Feng,
T. et al.
2010)
o
The
ISIS-2 trial,
the second
study of
infarct
survival,
indicated an
ASA dose of
160mg
chewedon
arrival to the
ED as soon
as a
diagnosis of
ACS is
suspectedor
made
decreases
mortality
rate.
(Matura, L.
A. et al.
2003)
o
He
Clopidogrel
has shown a
34%
reduction in
cardiovascul
ar death or
recurrent MI
when the
patient is
given a
loading dose
of 300mg
and then

75mg orally
daily.
(Matura, L.
A. et al.
2003)
o
Altho
ugh patients
with a
higher risk
score had an
increased
rate of
death or MI
within 42
days and
365 days (p
< 0.001) in
both
managemen
t strategies,
early
invasive
managemen
t for patients
in the high
and very
high risk
categories
was
associated
with a lower
rate of
death or MI
within 42
days
compared
with
conservative
managemen
t. (Solomon,
D. H. et al.
2001)
o
In
only one
study found
a
statistically
significant
beneficial
association

Abbasi, M. et el.
(2006). Prevalence of
diabetes and other
cardiovascular risk
factors in an Iranian
population with acute
coronary syndrome.
http://www.biomedcen
tral.com/ 14752840/5/15

Dia
betes and
Hypertens
ion are
leading
risk
factors,
which
may
directly or
indirectly
interfere
and
predict
more
serious
complicati
ons of
coronary
heart
disease.

4.
T
here
are
metho
ds
that
can be
done
to
patien
ts with
ACS.

between PA
and hospital
mortality.
After
combining
the data
found a
significant
reduction in
the
probability
of hospital
death in
patients
with PAD
( odds
ratio =
0.61,
confidence
interval
95%, from
0.48 to 0.78,
P <0.0001).
(IglesiasGarriz, I. et
al. 2008)
o
Ninet
y-seven
(46%) of
212 patients
assigned to
the CPU had
an
uncomplicat
ed stay and
negative
provocative
tests,
allowing
them to be
discharged
home. This
led to an
absolute
45.8% lower
admission
rate
compared
with those in
the routine

admission
group.
(Rabin, E. &
Bullard, M.
1999)
o
Altho
ugh patients
with a
higher risk
score had an
increased
rate of
death or MI
within 42
days and
365 days (p
< 0.001) in
both
managemen
t strategies,
early
invasive
managemen
t for patients
in the high
and very
high risk
categories
was
associated
with a lower
rate of
death or MI
within 42
days
compared
with
conservative
managemen
t. (Solomon,
D. H. et al.
2001)
o
The
approach to
risk
stratification
has evolved
during the
past 2
decades

from a
practice that
once
involved an
evaluation
for residual
ischemia
and for left
ventricular
dysfunction
after
myocardial
infarction
(MI).
However,
risk
stratification
has now
evolved
more to
include
assessment
of the risk of
future
cardiac
events,
which can
be predicted
on the basis
of clinical
features at
the time of
the initial
assessment
in the
emergency
department.
(Cannon, C.
P. 2005)
Solomon, D. H. et al.
(2001). Use of risk
stratification to
identify patients with
unstable angina
likeliest to benefit
from an invasive
versus conservative
management
strategy.
http://www.sciencedir

Ris
k
stratificati
on may
be an
effective
method
for
identifyin
g those
patients

ect.com/science
/article/pii/S07351097
01015030

Feng, T. et al. (2010).

Assessment of
coronary plaque
characteristic by
coherence
tomography in
patients with diabetes
mellitus complicated
with unstable angina
pectoris.
http://www.sciencedir
ect.com/science
/article/pii/S00219150
1000794X

with
unstable
angina
most
likely to
benefit
from early
invasive
managem
ent.

Sel
ective use
of early
managem
ent can
have a
substantia
l impact
in
reducing
morbidity
and
mortality
in higher
risk
patients,
but may
not be
warranted
in lower
risk
patients.

Hig
her
calcificati
on and
dissection
in were
detected
in diabetic
patients
with
unstable
angina
pectoris,
and the
difference
in
coronary
plaque

Norhammar, A. et al.
(2004). Diabetes
mellitus: the major
risk factor in unstable
coronary artery
disease even after
consideration of the
extent of coronary
artery disease and
benefits of
revascularization.
http://www.sciencedir
ect.com/science
/
article/pii/S07351097
03015407
Bakhai, A. et al.
(2005). Diabetic
patients with acute
coronary syndromes
in the UK: high risk
and under treated.
http://www.sciencedir
ect.com/science
/article/pii/S01675273
04004041
Iglesias-Garriz, I. et al.
(2008). Hospital
mortality and early
preinfarction angina:
meta-analysis of
published studies.
http://www.sciencedir
ect.com/science
/article/pii/S03008932
05739348

characteri
stics can
explain
the
difference
in clinical
prognoses
between
DM and
non-DM
patients.

Dia
betes
mellitus
remained
an
independ
ent and
important
risk factor
for death
and
myocardi
al
infarction
in the
invasive
group.

DM
is
common
amongst
patients
admitted
with ACS.

The
presence
of angina
during the
24 hours
before the
onset of
myocardi
al
infarction
was
associate

Cannon, C. P. (2005).
Evidence-based risk
stratification to target
therapies in acute
coronary syndromes.
http://circ.ahajournals.
org/content/
106/13/1588.full

Matura, L. A. et al.
(2003). Guidelines for
diagnosis and
management of
unstable angina and
non-ST-segment
elevation myocardial
infarction.
http://www.ispub.com/
journal/the-internetjournal-of-advancednursingpractice/volume-6number-1/guidelines-

d with a
significant
reduction
in hospital
mortality.

Clo
pidogrel
in
unstable
angina
have now
applied
the risk
score to
evaluate
the
newest of
the
beneficial
treatment
.

Ris
k
Stratificati
on has
been
found to
be very
useful in
identifyin
g the
relative
benefit of
new
interventi
ons.

Ant
i-platelets
prevent
the
formation
of
thrombox
ane A2
that
diminishe
s platelet
aggregati
on.

for-diagnosis-andmanagement-ofunstable-angina-andnon-st-segmentelevation-myocardialinfarction.html

Clo
pidogrel
works by
inhibiting
platelet
aggregati
on.

IV. CONCLUSION AND RECOMMENDATION

Angina pectoris is a syndrome characterized by episodes or paroxysms of pain or
pressure in the anterior chest. One type of this is the unstable angina. The pain is triggered by
an unpredictable degree of exertion or emotion. It attacks characteristically increase in number,
duration, and severity over time. And most causes appear to be related on having diabetes
mellitus, we conclude that the probable cause that triggered the unstable angina attack of Mr.
Santos was his type 2 diabetes mellitus. It contributes because DM patient has a thick blood
that may creates a clot or thrombus formation. This can decrease the flow that can result in
ischemia and cause to induce pain.
Having unstable angina may be a life changing disease. We recommend the patient
must learn the health and condition in order to manage the disease properly and appropriately

in case the disease will attack again and to promote healthy lifestyle. Instructed to do deep
breathing exercises. Instructed to choose low sodium snacks such as fresh fruit and vegetables.
Reduce the amount of alcohol you drink or to drink not at all. Too much alcohol damages heart
muscle. Instructed to avoid fatty foods intake. Instructed the client to avoid eating junkfoods and
avoid drinking softdrinks. Instructed to pick and wash the foods carefully.

V. NURSING CHALLENGES ENCOUNTERED

1) Chest pain
The pain or discomfort of angina pectoris is felt under the breastbone and
is usually transient. It signals a temporary imbalance between the demands of the heart
and the supply of oxygen-carrying blood that it is receiving. In most cases, angina is not
disabling, and many patients can lead active and productive lives by following
appropriate medical recommendations. ( by E.P Dutton, HEARTBOOK, The American
Association, USA, New York)
The patient had experienced chest pain for 1 year as for estimation. The
quality of chest pain experience is tight heaviness. It lasts for more than 15 minutes. The
chest pain occurs even at rest.
2) Non compliance to subcutaneous medications
Patient S.E.A verbalizes difficulty with regulation of prescribed regimen for
treatment of illness and its effect or prevention of complications acceleration of illness
symptoms. The patient complains of pain when administering subcutaneous meds.
Thats why he doesnt want to comply anymore to SQ meds.
According to Ackley Ladwig, Ineffective management of therapeutic
regimen is a pattern of regulating and integrating into daily living a treatment program for
an illness and its aftereffects that are unsatisfactory for meeting specific health goals.
3) Productive cough
Our patient had right pneumonia based on chest x-ray result. He also had
difficulty of breathing. According to E.P Dutton, acute inflammation of an area of the lung
resulting from bacterial invasion may have serious side effects on the heart, particularly
if there is an underlying heart disease. The body attempts to combat the infection by

increasing the demand for blood, in turn places an added burden on the heart, forcing it
to pump more blood with each beat. The degree of distress varies with the client
position, activity and level of stress.
4) Risk for imbalanced nutrition
The patient had difficulty swallowing. nahirapan ako lumunok kasi tuloytuloy yung pagkain ko stated by the patient. Patient had risk for altered nutrition
because of the inability to ingest food due to biological status. Altered nutrition is the
state in which an individual experiences an intake of nutrients insufficient to meet
metabolic needs.
5) Lifestyle of family (diet)
The client stated that they often eat fatty foods and oily foods in their
homes. They dont have proper nutritional diet plan and dont mind the foods that will
cause hypertension. These diets have been linked to the development of atherosclerosis
and hypertensive disease.
6) Activity Intolerance
The patient experienced body weakness and dizziness upon moving. He
had limited movement, weak in appearance, unable to sit or stand. He can do ADLs with
assistance. In addition, patients with angina pectoris learn to slow the pace of their
physical activity

VI. Nursing Solutions/Approaches Used

1) Chest pain

Provide massage (generalized cutaneous stimulation of the body)

R: used to stimulate non-pain receptors, which are thought to block or decrease the
transmission of pain impulses. It also produces muscle relaxation, which promotes
comfort.
-

Porth CM. Essentials of Pathophysiological: Concept of Altered Health States,

The Path to Managing Neuropathic Pain. Philadephia, Pa., Lippincott Williams and
Wilkins, 2006

Provide skeletal muscle relaxation such as slow, rhythmic abdominal breathing

R: it can relieve pain by relaxing tense muscles, which may contribute to pain. This is
also used as a distraction technique
-

Porth CM. Essentials of Pathophysiological: Concept of Altered Health States,

The Path to Managing Neuropathic Pain. Philadephia, Pa., Lippincott Williams and
Wilkins, 2006
2) Non compliance to subcutaneous medications
Interventions made to this nursing challenge are more on psychological
approach. Based on patients case we must teach safety in taking medications.. Another
is to teach about all aspects of therapeutic regimens; provide as much knowledge as
person will accept.
R: Knowledge of scientific rationales improves understanding of the therapeutic regimen
and increases responsibility for the therapeutic regimen. Although decisions about
actions to meet therapeutic goals are made by the client, the presence of the nurses,
and the collaborative nature of a nurse0client relationship can help the client with
decision-making
3) Productive cough

Assist in mobilizing secretion like increasing room humidification

Rationale: to facilitate airway clearance and to liquefy secretion

Encourage patient to cough out secretions if there is

Rationale: to have clear airway

Assist in bronchial tapping and back rub as a performed chest physical therapy if

needed and instruct relative to do it also

Rationale: to create vibration thus mobilizing secretion; chest physical therapy technique
using force of gravity and motion to facilitate secretion removal

Teach and supervise effective coughing technique

Rationale: proper coughing technique conserves energy, reduce lung collapse

Assess breath sounds before and after coughing episodes

Rationale: helps in evaluation of coughing effectiveness

Encourage slower/deeper respirations. Used of pursed-lip breathing

Rationale: to enhance lung expansion

Encourage to have adequate rest

Rationale: reduce fatigue, metabolic/ oxygen demand

Position appropriately like elevation the head and side-lying

Rationale: to prevent vomiting with aspiration into lungs

Encourage ambulation & exercise

Rationale: to promote good blood circulation thus improving good oxygenation

Maintain semi-fowlers position

Rationale: it decreases pressure on diaphragm by the use of gravity

Evaluate clients cough and swallowing ability

Rationale: to determine ability to protect own or airway

4) Risk for imbalanced nutrition
As for intervention these are the ff:

Provide companionship at mealtime to encourage nutritional intake.

R: mealtime usually is a time for social interaction

Eating small frequent meals

R: it reduces the sensation of fullness and decreases the stimulus to vomit.

5) Lifestyle of family (diet)
Dietary Approaches to Stop Hypertension (DASH) study have established that a
diet high in fruits, vegetables, and low in cholesterol and total and saturated fat reduces
BP significantly.
6) Activity Intolerance
Instructed to do active range of motion

VII. REFERENCES (APA FORMAT)

E.P Dutton, HEARTBOOK, The American Association, USA, New York
Black, JM, Hawks, JH, Keene, AM, (2002), Medical-Surgical Nursing, Elsevier Science
Singapore, 6TH Edition, volume 2, pp1579-1582
Smeltzer, Suzanne C., Medical-Surgical Nursing, Lippincott Williams & Wilkins 004,
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Doenges, Marilyn., Moorhouse, Mary Frances., Murr, alice C., Nurses Pocket Guide, F.A
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