NURSING CARE PLAN - SEMESTER II PN II

Student Name: Jennifer Post

Spirituality:

Client's Initials: RM
Gender: Female
Date of Care: 6/21/2016

Age: 52
Date of Admission: 6/17/16

Diagnosis: Fecal Incontinence

Faithful no religious affiliation

Cultural Preferences: None

Psychosocial/Social History: Divorced,(married for
15yrs) Six children, daily smoker; half pack per day,
ETOH; 25 cans of beer per week.

Surgical Procedure & Date:

Colostomy Closure 06/17/2016
Allergies/Reaction: Lactose Diarrhea
PT states that cheese and cottage cheese are ok in
moderation.

Client Admitting Presentation or History of Present

Illness (HPI): Closure of loop colostomy with segmental
colon resection, repair of ventral hernia with mesh.

Past Medical History:

Anxiety

Depression
Arthritis
Asthma
Colostomy
Fecal incontinent
GERD
Hypertension
Obesity
Rectal prolapse
Vitamin B12 deficiency
Difficult intubation
Pseudocholinesterase deficiency
Malignant hyperthermia
Sickle cell anemia.

Past Surgical History:

Hysterectomy

Robotic Sigmoid Colectomy & rectopexy

Breast reduction
Abdominoplasty
Laparoscopic loop colostomy & open
rectopexy
Anal sphincteropalsty
Colostomy
Colonoscopy
Gastric bypass
Colon surgery

Disciplines role in care of client:

Physician: Physicians must be dedicated to improving the quality of health care. They also must ensure that

patients are completely and honestly informed before the patient has given consent to treatment and after
treatment has occurred. Physicians are responsible for meeting the medical needs of patients by diagnosing
and working with other physicians, hospitals, to develop guidelines for effective care.
RN: Perform a wide variety of job duties during their shifts. Including caring for and educating patients about

their conditions, as well as establishing trust and building rapport with patients and their families. They perform
physical exams and health histories. Provide health promotion, counseling and education. Administer
medications, wound care, and numerous other personalized interventions.
LPN: Perform a wide variety of job duties during their shifts. Including caring for and educating patients about

their conditions, as well as establishing trust and building rapport with patients and their families. They perform
physical exams and health histories. Provide health promotion, counseling and education. Administer
medications, wound care, and numerous other personalized interventions.
Patient Care Technician or Unlicensed Assistive Personnel: Assist patients with many tasks that they cannot do

for themselves while they are in hospitals, rehabilitation clinics, assisted living facilities, nursing homes or longterm care facilities. They work under the supervision of an LPN, or RN.
Social Worker: Social workers typically work in a hospital, skilled nursing facility or hospice, and work with

patients and their families in need of psychosocial help. Medical social workers assess the psychosocial
functioning of patients and families and intervene as necessary.
Care Manager: Is an advocate who ensures patients are satisfied with their health care. This professional's job

is to also ensure that a facility is providing high quality care services, as well as work with administration, staff,
and patients to reach health care goals.
Dietician: Explain nutrition issues to clients, assess the dietary and health needs of clients or patients in

developing meal plans. They gauge the effects of these meal plans, promote nutrition through public speaking
and community outreach programs, and keep on top of the latest research in nutritional and food sciences.
Medical Laboratory: Medical laboratory technicians play an important role in the prevention and diagnosis of

diseases, such as cancer, diabetes and AIDS. Medical lab technicians work under the supervision of a
physician, lab manager or medical technologist and perform laboratory tests on specimens. The tests that lab
techs conduct assist doctors in verifying the causes of an illness, making medical decisions and determining
treatment options.
Physical Therapist: Physical therapists help people with physical injuries or illnesses regain range of

movement and control their pain. PTs, help people who have lost motor function due to accidents, illness or
age. They help determine the root causes of the trauma, and work with them to create a plan for rehabilitation.
PTs typically create plans that involve stretching, strength training, exercises and physical movements to help
people recover. They are experts at what the body can do, and will educate patients and families about what is
possible, and keep patients motivated during ongoing therapy. PTs also track progress and report to patients
and their families.

Occupational Therapist: The role of the Occupational Therapist (OT) is to help patients improve or maintain

skills for day-to-day activities and well-being. OTs work together with their patients to identify important and
valued activities that are difficult to do because of illness or physical limitations. The activities may be related to
self care, paid or unpaid work, or leisure and fun. Together they will find ways to use the patients strengths
and resources to lead productive and satisfying lives.
Home Care: Home care assistants are trained to assist the elderly, disabled, mentally ill, and/or terminally ill.

Home care assistants often work in private homes to help patients with daily tasks such as personal grooming
and meal preparation. Families sometimes bring in these workers to care for their loved one when the job
becomes too much for them to handle. Depending on the condition of the patient, actual feeding may be
necessary. Light, general housekeeping may also be expected of a home care assistant.
Pastoral Care: Chaplains provide one-to-one, short-term support to patients, their families and hospital staff.

The department operates on a referral basis and receives requests from nursing, physicians, social workers,
patient representatives, clergy, patients and family members. In addition, chaplains are included in a number of
hospital emergency protocols. Chaplains also provide support, counseling, and referral for hospital staff and
their families and limited outpatient counseling and support to former patients and their families.
Student Nurse: Students are obligated with special responsibilities. Students apply their knowledge and skills in

the care of patients/residents under the guidance of an instructor and/or preceptor. Students' behavior should
reflect the values of the health care organization at all times. Policies and guidelines for clinical placements are
designed to facilitate student identity, patient/resident safety and comfort, and infection control.

Other: Respiratory therapists are required to diagnose lung disease and breathing disorders, and then

recommend the most appropriate treatment methods. Their work often includes examining patients, performing
chest exams, and analyzing tissue specimens. Along with having an extensive knowledge of the
cardiopulmonary system, respiratory therapists must be experts in the machines and devices used to
administer respiratory care treatments. This would involve managing patients on ventilators and artificial airway
devices, and assessing the blood-oxygen level of patients.

Lab Test

Normal
Value(s)

Lab Result

Lab Value Analysis

Indication(s)
-Define what the test is

Clinical S
-How do
to the d

BMP
NA
K
BUN
Creatnine
Glucose
Ca

135-145
3.5-51
8-20
0.5-0.9
100-125
8.5-10.4

138

WBC
RBC
HGB
HCT
Platelet
Count

4.0-11.0
3.80-5.20
12.0-16.0
35-47
150-450

10.2
4.02
12.7
40
190

Protime
INR
APTT
MCV
MCH

9.0
0.8-1.1
70-120
80-96
27-33

Not ordered
Not ordered
Not ordered
99
31.6

Test

4.1

9
0.6
135
9.0

Results

Sodium - Electrolyte level

Potassium Electrolyte level
Evaluates kidney function
Evaluates kidney function
Evaluates blood glucose levels
Measures the level of calcium in the
blood.
CBC w/ Diff
White Blood Cell count
Red Blood Cell Count
Hemoglobin count
Hematocrit
To determine the number of platelets
in blood.
Other

Indicator for enlarged RBC

Hemoglobin content in the RBC
Microbiology
Test
NO MICROBIOLOGY LABS ORDERED

Helps eva
Helps eva
Ensures th
Ensures th
Evaluating
Evaluates
and kidney

Indicator fo
Indicator fo
Indicator fo
Determine
Ordered to
bleeding.

N/A
N/A
N/A
Lab ordere
Lab ordere

Diagnostic Tests
Test

What is the purpose of this test?

No diagnostic tests ordered at time
of hospitalization.

Results

MEDICATIONS
Drug

Dose

Route

Freq

Classification

Amlodipine
(Norvasc)
Amoxicillin
(Augmentin)
Escitalopram
oxalate (Lexapro)
Heparin
(Porcine)
Lisinopril
(Prinivil,Zestril)
Pantoprazole
(Protonix) EC

5mg

Oral

Daily

125mg

Oral

BID

Calcium Channel
Blocker
Antibiotic

20mg

Oral

Daily

Anti depressant

7500
units
20mg

q8h

Blood thinner

Oral

Sub
Q
Daily

40mg

Oral

BID

proton pump
inhibitor

Sodium Chloride
0.9% Lock Flush

3ml

IV

TID

Fluid & electrolyte

replenishment

ACE Inhibitor

Indications for use

Actual effect on client.

Give specific examples.
Treatment for hypertension BP before medication
150/100 after med 110/72
Surgical prophylaxis
Pt shows no indications of
infection.
Depression
No visual or audio
indications of depression
Used to prevent blood
No indications of blood
clots after surgery
clots.
Treatment for hypertension BP before medication
150/100 after med 110/72
Decreases the amount of
Decreased signs and
acid produced in the
symptoms of GERD
stomach.
To keep IV patent
None

PRN Medications
Acetaminophen
(Tylenol)
Albuterol
(Proventil)

650mg

Oral

q6h

Analgesic

Treatment for mild pain

Rating 1-4/10
Wheezing

2.5mg

Nebulizer

q6h

Bronchodilator

HydrocodoneAcedtminophen
(NORCO)
Hydromorphone
(Dilaudid)
Ondansetron
(Zofran)

325mg

Oral

q4h

Opioid

Treatment for Severe pain

Rating 5-10/10

Pt states having very little

pain. Pain rating of 2/10.
Pt wheezing before neb
treatment. No wheezing
after.
Pt states having severe
pain. Rating 8/10

0.5mg

IV

q2h

Opioid

4mg

IV

q6h

antiemetic and
selective 5-HT3
receptor antagonist

Treatment for severe

breakthrough pain
Treatment for
Nausea/Vomiting

None- pt did not need

during cares.
Pt did not request any at
time of cares.

Care Plan Worksheet

Semester II PN II

Assessment

Name:
Subjective Data
My stomach hurts
Its a 7 out of 10, it hurts real bad.
Can I have some more pain
medicine?
Why does it hurt so bad?

Date:
Objective Data
Reported pain 7/10
Protective body positioning
Restlessness
Pallor
Pupil dilation
Change in BP, HR, R from normal
baseline data

Student Instructions: To be sure your client diagnostic statement written below is accurate

Diagnosis

you need to review the defining characteristics and related factors associated with the nursing
diagnosis and see how your client data match. Do you have an accurate match or are
additional data required, or does another nursing diagnosis need to be investigated? Do you
have all the 2 or 3 parts in your diagnosis statement? (Nanda Dx r/t AEB) or (At risk for
NANDA Dx r/t)

Nursing Diagnosis: Acute Pain R/T post operative surgical incision AEB; pallor;
elevated pulse, respirations, and systolic blood pressure and report of 7/10 abdominal
pain.
Medical Diagnosis: Closure of loop colostomy with segmental colon resection, repair
of ventral hernia with mesh.
Pathophysiology of the medical diagnosis: Closure of loop colostomy with
segmental colon resection is a surgery performed with prior consent to close the
original colostomy and reconnect the colon. This is done because a loop colostomy is
a temporary stoma in which the entire loop of colon is exteriorized.

Planning

Client Outcome
Student Instructions: The desired outcome must meet criteria to be accurate. The outcome
must be specific, realistic, measurable, and include a time frame for completion. Does the
action verb describe the client's behavior to be evaluated? Can the outcome be used in the
evaluation step of the nursing process to measure the client's response to the nursing
interventions listed below? Is it written in 3 parts: Pt will (rewrite the NANda in the positive)
..time frameAEB (rewrite the subj/obj data in the positive)..?

Short Term Goal: (Minutes, hours, days, before day of discharge)

Patient verbalizes that pain is relieved and or controlled within 60 minutes from when
analgesic pain medication is administered. Stating a pain scale of less than 3 out of 10.

Interv

Long Term Goal: (Weeks, months, year, before next provider appointment)
Patient will have no pain after one month from day of discharge.

Interventions

Rationale for Interventions

This MUST come from a textbook or
credible source: website, journal, article

ention

1. Reduce or eliminate factors that

precipitate or increase the patients pain
experience.

1. Personal factors can influence pain and

pain tolerance. Factors that may be
precipitating or augmenting pain should be
reduced or eliminated to enhance the
overall pain management.

2. Perform a comprehensive
assessment of pain to include location,
characteristics, onset, duration,
frequency, quality, intensity or severity,
and precipitating factors of pain.
3. Instruct patient to request prn pain
medication before the pain is severe.

2. Helps evaluate degree of discomfort and

effectiveness of pain medication that was
administered or may reveal developing
complications.

4. Obtain a prescription to administer a

non-opioid for pain management.

4. Unless contraindicated, all patients with

acute pain should receive a non-opioid The
analgesic regimen should include a nonopioid, even if pain is severe enough to
require the addition of an opioid.
5. Nonpharmacological interventions should
be used to supplement, not replace,
pharmacological interventions. Easier to
control pain when pharmacological
interventions are not available.

5. Teach and implement nonpharmacological interventions when pain

is relatively well controlled with
pharmacological interventions.

3. Severe pain is more difficult to control

and increases the clients anxiety and
fatigue.

Evaluation

What was your clients response to the interventions? Be very specific. Was the
desired outcome achieved? If no, what revisions to either the desired outcomes or
interventions would you make?
1. The patient was happy to have fewer visitors, as they caused her stress. This was
a temporary relief for the patient but allowed her to rest comfortably and helped to
reduce her pain.
2. Figuring out what the cause of the pain was for the patient allowed the RN to give
her a medication that targeted the area causing the pain. The patient responded very
well to the analgesic.
3. Patient requested pain medication at early onset. This was pain management
intervention was successful for the patient.
4. Administering an analgesic medication to the patient was a successful intervention.
It reduced her level of pain from 7 out of 10 to 3 out of 10. For her this was much more
manageable.

Patient

5. Working with the patient on using the Hug Me pillow as well as slow deep
breathing helped to elevate some of the pain without having to use a pharmaceutical
pain management medication.
Student Instructions: Please list one thing you have taught your patient today. It
may be as simple as teaching them how to get out of bed to the chair or as complex a
medication teaching. There is always at least one thing you have taught throughout
your day.

Maslows Hierarchy of Needs Teaching

I was able to speak with the patient regarding the use of her Hug me pillow and how it
will help provide comfort and reduce pain at her incision site when moving, coughing or
laughing. The patient was very receptive to using the hug me pillow and started to do
so while we were still in conversation.
Identify which stage in Maslows hierarchy of needs your NANDA relates to and how it relates
to this stage.

Patient is in the physiological state currently because of the acute pain that she is
feeling. Once the patient is able to find relief from her pain, she will be able to move
toward the safety phase.

Care Plan Worksheet

Semester II PN II
Name:

Date:
Objective Data

Diagnosis

Assessment

Subjective Data
I dont know how to take care of this.
Referring to her incision wound.
Its nasty, I dont want to touch that.

Patient appears anxious when talking

about taking care of her incision site at
home.

Pt looks away from incision during

Why do I have to do that?
dressing changes.
Student Instructions: To be sure your client diagnostic statement written below is
accurate you need to review the defining characteristics and related factors associated
with the nursing diagnosis and see how your client data match. Do you have an
accurate match or are additional data required, or does another nursing diagnosis need
to be investigated? Do you have all the 2 or 3 parts in your diagnosis statement?
(Nanda Dx r/t AEB) or (At risk for NANDA Dx r/t)
Nursing Diagnosis: Deficient knowledge R/T wound care at home. AEB I dont know
how to take care of that. Patient shows lack of interest in the incision site and how to
change the dressing.

Medical Diagnosis: Closure of loop colostomy with segmental colon resection, repair
of ventral hernia with mesh.
Pathophysiology of the medical diagnosis: Closure of loop colostomy with
segmental colon resection is a surgery performed with prior consent to close the
original colostomy and reconnect the colon. This is done because a loop colostomy is
a temporary stoma in which the entire loop of colon is exteriorized.
Client Outcome

Planning

Student Instructions: The desired outcome must meet criteria to be accurate. The

outcome must be specific, realistic, measurable, and include a time frame for
completion. Does the action verb describe the client's behavior to be evaluated? Can
the outcome be used in the evaluation step of the nursing process to measure the
client's response to the nursing interventions listed below? Is it written in 3 parts: Pt
will (rewrite the NANda in the positive)..time frameAEB (rewrite the subj/obj data in
the positive)..?
Short Term Goal: (Minutes, hours, days, before day of discharge)
Patient is able to verbalize the need for daily dressing changes that must be done daily
to prevent infection within the new surgical incision site by day of discharge. Patient is
able to demonstrate proper way to change her wound dressing before discharge.
Long Term Goal: (Weeks, months, year, before next provider appointment)
Patient will be able to provide a List of resources that can be used for more information
or support after discharge. Patient will also be able to discontinue dressing changes
within 3 to 4 weeks from discharge.
Interventions

Intervention

1. Observe client's ability and readiness

to learn. Education in self-care must take
into account physical, sensory, mobility,
sexual, and psychosocial changes
related to age.
2. Assess barriers to learning (e.g.,
perceived change in lifestyle, financial
concerns, and cultural patterns, lack of
acceptance by peers or coworkers).

Rationale for Interventions

This MUST come from a textbook or
credible source: website, journal, article
1. Knowing the patients readiness will
allow for better teaching experience for
both the patient and the care provider. If the
patient is not ready to learn they will not
remember any of the information that is
needed to be learned.
2. Assessing for barriers will help to know
how to teach the patient. Example, If the
patient is unable to read then a different
form of teaching may be needed such as
visuals or audio.

3. Evaluate client's learning through

return demonstrations, verbalizations, or
the application of skills to new situations.
Presenting information along with
examples of how to apply the
information.

3. Working with the patient directly on the

daily dressing changes will reinforce the
skill that is needed to be learned. This will
allow for the patient to ask questions and
reinforce the positives of doing it correctly.

4. Assess willingness of family to

incorporate new information,
immunizations, medical care in support
of the client.

4. Working with the patient and their family

members or support members will allow for
the patient to have extra care and support
when home or away from clinical setting.

5. Help patient identify community

resources for continuing information and
support.

5. Community resources can offer financial

and educational support. Reinforcing the
topics that are taught to the patient and
allow for later reinforcement.

Evaluation

What was your clients response to the interventions? Be very specific. Was the
desired outcome achieved? If no, what revisions to either the desired outcomes or
interventions would you make?
1. The patient was open to learning about her incision and why it looked the way it did.
Once she really looked at it and made her own judgments about it she was able to
move forward and starts to work on learning about the care of her wound.

2. Patient did not appear to have any barriers to learning physically. Being able to
concentrate while others were in the room was a distraction. Family was asked to
leave for a short time and could return later for their teaching time. This was successful
and allowed for a positive teaching experience.
3. Patient was very receptive to learning through demonstration. Patient was able to
perform wound care on herself with the guidance of the RN. This was successful and
was repeated with each dressing change.
4. Patients family was a bit hesitant to learn about the patients incision and how to
care for it. The patient herself was able to explain why she might need help and with
what steps with the dressing change. Once this was established the family members
were willing to learn how they could help their loved one. This was a successful
teaching method as well.

Patient Teaching

5. The patient and family members along side with a wound care nurse were able to
establish a listing of community resources for the patient to refer to if un able to reach a
doctors office first. This provided comfort to both the patient and the family members.
Student Instructions: Please list one thing you have taught your patient today. It
may be as simple as teaching them how to get out of bed to the chair or as complex a
medication teaching. There is always at least one thing you have taught throughout
your day.
I was able to teach my patient about the importance of changing her dressing daily. We
discussed what could happen if this was not completed and what will happen when it is
done in a sterile manner as well. This conversation with the help from the wound care
nurse was able to provide a base for understand and openness to learn about her
cares.

Maslows Hierarchy of Needs

Identify which stage in Maslows hierarchy of needs your NANDA relates to and how it relates
to this stage.

Patient is in the physiological state currently because of deficient knowledge related to

wound care. Once the patient is able to establish a comfortable understanding of her
cares, she will be able to move toward the safety phase.

Care Plan Worksheet

Semester II PNII
Name:

Date:

Diagnosis

Assessment

Subjective Data

Objective Data

How am I going to get an infection, its

covered?

This is why I want to stay here longer.

Patient is not careful with touching her

dressing on her wound with unwashed
hands.
Kids like looking at it up close.
Patient is a noted smoker

Student Instructions: To be sure your client diagnostic statement written below is

accurate you need to review the defining characteristics and related factors associated
with the nursing diagnosis and see how your client data match. Do you have an
accurate match or are additional data required, or does another nursing diagnosis need
to be investigated? Do you have all the 2 or 3 parts in your diagnosis statement?
(Nanda Dx r/t AEB) or (At risk for NANDA Dx r/t)
Nursing Diagnosis: At increased risk for infection R/T insufficient knowledge
regarding avoidance of exposure to pathogens.

Medical Diagnosis: Closure of loop colostomy with segmental colon resection, repair
of ventral hernia with mesh.
Pathophysiology of the medical diagnosis:
Closure of loop colostomy with segmental colon resection is a surgery performed with
prior consent to close the original colostomy and reconnect the colon. This is done
because a loop colostomy is a temporary stoma in which the entire loop of colon is
exteriorized.
Client Outcome

Planning

Student Instructions: The desired outcome must meet criteria to be accurate. The

outcome must be specific, realistic, measurable, and include a time frame for
completion. Does the action verb describe the client's behavior to be evaluated? Can
the outcome be used in the evaluation step of the nursing process to measure the
client's response to the nursing interventions listed below? Is it written in 3 parts: Pt
will (rewrite the NANda in the positive)..time frameAEB (rewrite the subj/obj data in
the positive)..?
Short Term Goal: (Minutes, hours, days, before day of discharge)
Patient will wash hands every time before changing her dressing with the wound care
nurse before discharge.

Intervention

Long Term Goal: (Weeks, months, year, before next provider appointment)
Patient will maintain free of infection until incision site is healed and dressing changes
are no longer needed in an estimated 3 to 4 weeks.
Interventions
1. Observe and report signs of infection
such as redness, warmth, discharge, and
increased body temperature.

Rationale for Interventions

This MUST come from a textbook or
credible source: website, journal, article
1. With the onset of infection the immune
system is activated and signs of infection
appear.

2. Assess skin for color, moisture,

texture, and skin turgo. Keep accurate,
ongoing documentation of changes.

2. Preventive skin assessment protocol,

including documentation, assists in the
prevention of skin breakdown. Intact skin is
nature's first line of defense against
microorganisms entering the body.

3. Encourage adequate rest to bolster

the immune system.

3. Chronic disease and physical and

emotional stress increase the client's need
for rest.

4. Use proper hand washing techniques

before and after giving care and any time
hands become soiled, even if gloves are
worn.

4. Washing hands is the number one way

to prevent the spread of infections.

5. Follow Standard Precautions and

wear gloves during any contact with
blood, mucous membranes, non-intact
skin, or any body substance except
sweat.

5. The purpose of wearing gloves is to

protect the hands from becoming
contaminated with dirt and microorganisms
or to prevent the transfer of organisms that
are already present on the hands.

Evaluation

What was your clients response to the interventions? Be very specific. Was the
desired outcome achieved? If no, what revisions to either the desired outcomes or
interventions would you make?
1. Pt shows no current sign or symptom of infection. Any signs and symptoms should
be reported to the provider. Pt states verbally an understanding of the signs and
symptoms and understands the importance of notifying her provider.
2. A skin assessment is completed with each dressing change. This is tolerated well
and is a great way for the nurse and patient to evaluate for signs and symptoms of
infection.
3. Patient was encouraged to rest as much as possible. Encouraged family to allow
patient to rest as well. Patient stated she was tired and would rest as much as she
could. This will encourage healing.
4. Patient was instructed on adequate hand washing. Teaching the patient this will
promote proper care and cleanliness when changing her dressing. The Patient was
very receptive to learning this.

Patient

5. The patient was provided information regarding wearing gloves when changing her
dressing. As well as where she acquire them once she goes home.
Student Instructions: Please list one thing you have taught your patient today. It
may be as simple as teaching them how to get out of bed to the chair or as complex a
medication teaching. There is always at least one thing you have taught throughout
your day.

Teaching

I was able to teach the patient and their family the symptoms of infection that should be
promptly reported to a primary medical caregiver (e.g., redness; warmth; swelling;
tenderness or pain; new onset of drainage or change in drainage from wound; increase
in body temperature;)

Maslows Hierarchy of Needs

Identify which stage in Maslows hierarchy of needs your NANDA relates to and how it relates
to this stage.

Patient is in the physiological state currently because of deficient knowledge related to

wound care. Once the patient is able to establish a comfortable understanding of her
cares, she will be able to move toward the safety phase.

Work Cited

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2012). Nurse's pocket guide: Diagnoses,
prioritized interventions, and rationales (14th ed.). Philadelphia, PA: F.A. Davis.

Mayo Clinc. (2016, July). Retrieved July 30, 2016, from Mayo Clinc:
http://www.mayoclinic.org/
Sanoski, C. A., & Vallerand, A. H. (2016). Davis's drug guide for nurses (15th ed.). Philadelphia,
PA: F.A. Davis.