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Chapter 47 Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. The Heart About the size of a fist Located within the mediastinum Pumps approximately 1000 gallons of blood every day Divided into four chambers All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2 Chambers of the Heart deoxygenated Right atrium oxygenated Left atrium Receives deoxygenated blood from the body Pumps blood to the right ventricle Right ventricle Pumps blood into the pulmonary artery Receives oxygenated blood from the pulmonary vein Pumps blood to the left ventricle Left ventricle Pumps oxygenated blood to the body through the aorta All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3 Valves of the Heart The tricuspid valve is located between the right atrium and right ventricle The pulmonary semilunar valve is located between the right ventricle and the pulmonary artery The bicuspid valve is located between the left atrium and left ventricle The aortic semilunar valve is located between the left ventricle and the aorta The opening and closing of the AV valves creates the characteristic “lubb,” first heart sound The opening and closing of the semilunar valves creates the characteristic “dubb,” or second heart sound All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4 The Conduction System of the Heart Sinoatrial (SA) node—the pacemaker of the heart Atrioventricular (AV) node slows the impulse to allow the atria to fill the ventricles The AV node also serves as a secondary pacemaker The bundle of His Purkinje fibers All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5 Coronary Blood Flow Blood enters coronary blood flow through the right and left coronary arteries Flows through coronary circulation Returns to systemic circulation via coronary veins All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6 Diagnostic Tests (PTEC 150 Obj.#1) A number of diagnostic tests are used to evaluate coronary function Diagnostic imaging Cardiac catheterization and angiography Electrocardiography Cardiac monitors Thallium scanning Echocardiography Positron emission tomography MUGA scan Laboratory tests All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7 Diagnostic Imaging Radiography Angiogram Aortogram All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8 Cardiac Catheterization and Angiography An invasive procedure used to visualize the heart’s chambers, valves, great vessels, and coronary arteries Used to measure Pressure within the heart Blood-volume relationship to cardiac competence Valvular defects, arterial occlusion, and congenital anomalies are determined All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9 Electrocardiography ECG or EKG A graphic study of the electrical activities of the myocardium to determine transmission of cardiac impulses through the muscles and conduction tissue All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10 Cardiac Monitors Telemetry Exercise stress ECG, or stress test Thallium scanning Echocardiography PET scan MUGA scan All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11 Laboratory Tests CBC PT/INR Erythrocyte sedimentation rate Serum electrolytes Serum lipids Arterial blood gases Serum cardiac markers B-type natriuretic peptide (BNP) Homocysteine C-reactive protein All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12 Risk Factors for Cardiovascular Disease PTEC 150 Obj.#4 Non-modifiable Risk Factors Family Gender Age Ethnicity All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13 Risk Factors for Cardiovascular Disease cont’d Modifiable Risk Factors Smoking Hyperlipidemia Hypertension Diabetes mellitus Obesity Sedentary lifestyle Stress Psychosocial All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14 PTEC 150 Obj. #3 Describe at least 5 common DO of the heat and related nursing care All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15 Cardiac Dysrhythmias A dysrhythmia (or arrhythmia) refers to any cardiac rhythm that deviates from normal sinus rhythm Normal sinus rhythm Rate: 60-100 bpm P waves: precede each QRS complex (atrial depolarization) P-R interval: interval between atrial and ventricular repolarization QRS complex: ventricular depolarization T wave: ventricular repolarization Rhythm: regular All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16 Cardiac Dysrhythmias cont’d Sinus tachycardia Sinus bradycardia Supraventricular tachycardia Atrial fibrillation Atrioventricular block Premature ventricular contractions Ventricular tachycardia Ventricular fibrillation All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 17 Angina Pectoris Table 8-3 p. 334 Refers to thoracic pain or choking caused by decreased oxygen of the myocardium Atherosclerosis of the coronary arteries is the most common cause Pain is the characteristic symptom of angina pectoris All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 18 Angina Pectoris cont’d Assessment Subjective data Patient reports of pain Feeling of impending doom Objective data Signs of pain Increased pulse Increased blood pressure Increased respiratory rate Anxiety Diaphoresis All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 19 Angina Pectoris cont’d Diagnostic Tests ECG may reveal ischemia and rhythm changes Exercise stress test may show ischemic changes Coronary angiography may show changes All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 20 Angina Pectoris cont’d Medical Management and Surgical Interventions Antiplatelets Vasodilators Beta blockers Calcium channel blockers Nitrates Coronary artery bypass graft Percutaneous transluminal angiography All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 21 Angina Pectoris cont’d PTEC 150 Obj.# 2 Nursing Interventions Promote comfort Promote tissue perfusion Promote rest Reduce anxiety Promote feelings of well-being Provide patient education **** Reduce the workload of the heart**** All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 22 Myocardial Infarction Table 8-3 p 334 An occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium caused by atherosclerosis or an embolus An asymptomatic MI may occur Pain is the leading symptom of MI Pain not relieved by nitroglycerin or rest All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 23 Myocardial Infarction cont’d Assessment Pain (OPQRST) Tachycardia Weak pulse Hypotension Diaphoresis Vomiting Pale skin Labored respirations Cardiac dysrhythmias All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 24 Referred pain - MI All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 25 MI - Women All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 26 Myocardial Infarction cont’d Diagnostic Tests Troponin T Troponin I ECG 12-lead ECG Echocardiogram PET scan MUGA scan All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 27 Myocardial Infarction cont’d Medical Management Focuses on preventing further tissue injury MONA: Morphine, oxygen, nitroglycerine, aspirin Beta blockers Calcium channel blockers Fibrinolytics PTCA CABG “Time is muscle” All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 28 Myocardial Infarction cont’d Nursing interventions Administer medications Avoid excess fatigue Assist with ADLs Encourage and provide education about cardiac diet Prevent complications Encourage patient to discuss feelings All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 29 Heart Failure When the heart has become unable to meet the metabolic demands of the body Patient may have Left ventricular failure Right ventricular failure PE CHF All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 30 Heart Failure cont’d Assessment Dyspnea Orthopnea Jugular venous distention (JVD) Fluid retention Ascites Peripheral edema Weight gain is the most sensitive indicator All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 31 Heart Failure cont’d Diagnostic Tests CBC – complete blood count BMP – basic metabolic panel – electrolytes,etc BNP - B type natriuretic peptide hormone ABGs - Arterial blood gasses ECHO- sonogram of the heart ECG – electrical conduction MUGA scan – cardiac function, ejection fraction BUN - Blood Urea Nitrogen – decreased glomerular filtration All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 32 Heart Failure cont’d Medical Management Loop diuretics Thiazide diuretics Diuretics work to reduce fluid build up – treat edema & pulmonary congestion Nitrates: medications used for treating or preventing chest pain (angina) caused by heart disease, usually of the arteries in the heart. Nitrates are vasodilators (dilators of blood vessels that increase their diameter) that allow blood to flow more easily. Digoxin – increase cardiac efficiency All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 33 ACE inhibitors: Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system by narrowing your blood vessels and releasing hormones that can raise your blood pressure. This narrowing can cause high blood pressure and force your heart to work harder. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 34 Beta blockers: also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. When you take beta blockers, the heart beats more slowly and with less force, thereby reducing blood pressure All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 35 ARBs: Angiotensin II receptor blockers (ARBs) are medications that block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on the muscles surrounding blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced. Diet Fluid restriction Oxygen All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 36 Heart Failure cont’d Nursing Interventions Monitor vital signs Monitor fluid status Assess lung sounds Monitor urinary output Assess edema – lower extremity - sacrum Assess for signs and symptoms of pulmonary edema Daily weight 1Liter fluid = 1 kg or 2.2 lbs. So, a weight gain of 2.2 lbs. means the patient has a liter of excess fluid All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 37 Valvular Heart Disease Stenosis – definition? Insufficiency All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 38 Valvular Heart Disease cont’d Assessment Fatigue Weakness Pain Nocturnal dyspnea Orthopnea Crackles Edema All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 39 Valvular Heart Disease cont’d Medical Management and Nursing Interventions Commissurotomy is an open-heart surgery that repairs a mitral valve that is narrowed from mitral valve stenosis. During this surgery, a person is put on a heart-lung bypass machine. The surgeon removes calcium deposits and other scar tissue from the valve leaflets. Valve replacement Assist with ADLs Administer prescribed medications Assess oxygenation status – O2 Sat All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 40 Patient Teaching for Cardiac Disorders Diet Medications Procedures Rest Smoking cessation Exercise All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 41 Cardiac Rehabilitation Cardiac rehabilitation has two major parts Exercise training to help the patient learn how to exercise safely, strengthen muscles, and improve stamina Education, counseling, and training to help the patient understand his or her heart condition and find ways to reduce the risk of future heart problems All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 42 Pulmonary Edema The accumulation of extravascular fluid in lung tissues and alveoli, most often caused by heart failure (HF) An acute and extensive life-threatening complication of HF caused by severe left ventricular dysfunction See blue box 8-5 & 8-6 & green table 8-7 All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 43 Pulmonary Edema cont’d Clinical Manifestations and Medical Management Severe respiratory distress Pink sputum Frothy sputum For assessment see Box 47-5 Diagnosed by radiograph of the chest Medical management involves simultaneous interventions to promote oxygenation, improve cardiac output, and reduce pulmonary congestion All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 44 Pulmonary Edema cont’d Nursing Interventions Promote oxygenation Promote venous return to the heart Promote adequate respiration Monitor I&O Monitor electrolytes All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 45 Rheumatic Heart Disease Is a result of rheumatic fever Arises from group A or group B streptococcus infection – strep throat! Characterized by fever, epistaxis, tachycardia, and nodules on joints Assessment will reveal joint pain, chest pain, or other manifestations associated with complications Valvular manifestations will mimic valvular disease It is diagnosed through signs and symptoms and lab values All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 46 Rheumatic fever Sydenham chorea is a major sign of acute rheumatic fever. The person may currently or recently have had the disease. may be the only sign of rheumatic fever in some patients. occurs most often in girls before puberty, but may be seen in boys. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 47 Erythema marginatum – rheumatic fever All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 48 Rheumatic Heart Disease cont’d Medical Management Prevention is the best management NSAIDs Antibiotics If needed, valve repair or replacement All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 49 Rheumatic Heart Disease cont’d Nursing Interventions Promote rest as indicated by patient’s condition Administer prophylactic antibiotics as prescribed Provide patient education regarding dental procedures All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 50 Pericarditis Inflammation of the pericardium caused by bacteria, fungus, or virus Characterized by retrosternal chest pain that is worse when lying supine Chest pain should be thoroughly assessed Patient should be assessed for general aches and fatigue Diagnosis made through careful assessment and lab values The nurse should evaluate the patient and monitor vital signs Supportive care should be provided All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 51 Endocarditis Inflammation of the endocardium IV drug abusers are the most frequently affected Patient complains of flulike symptoms and chest pain, and may have splinter hemorrhages or petechiae Treatment involves rest and antibiotics Surgery may be required Nursing interventions are aimed at symptom control and promoting rest and comfort All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 52 Cardiomyopathy Cardiomyopathy is a term used to describe a group of heart muscle diseases that primarily affect the structural or functional ability of the myocardium Dilated Hypertrophic Restrictive All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 53 Cardiomyopathy cont’d Causes Infection Metabolic disorders Severe nutritional disorders Alcohol abuse Peripartal disorders Drugs Radiation therapy Lupus Rheumatoid arthritis Cocaine abuse All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 54 Cardiomyopathy cont’d Clinical Manifestations The patient may have symptoms of heart failure, edema, or hepatic dysfunction Medical management includes ACE inhibitors, antidysrhythmics, or beta blockers Heart transplantation All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 55 Effects of Aging on the Heart Blood vessels become thicker and less compliant Peripheral vascular resistance increases, causing a rise in blood pressure Atherosclerotic changes in the blood vessels increase All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 56 PTEC 150 obj #6 Describe at least 4 Dos of the blood vessels ad discuss related nursing care All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 57 Arterial Disorders Assessment Intermittent claudication Strength of pulses PATCHES mnemonic Pulses Appearance Temperature Capillary refill Hardness Edema Sensation All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 58 Arterial DOs Atherosclerosis Arteriosclerosis Sometimes used interchangeably Thickened narrowed arteries Plaques, Hardened calcified vessel walls All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 59 PAD: peripheral arterial dz 5 P’s Pain Pulselessness Pallor Paresthesia Paralysis Pp. 362-363 clinical manifestations All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 60 Venous Disorders Assessment Chronic edema Stasis ulcers Peripheral pulses are present All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 61 Hypertension Essential Secondary Malignant All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 62 Hypertension cont’d Essential hypertension (HTN)—there is no underlying cause Accounts for 90-95% of HTN cases Secondary HTN occurs as the result of a comorbidity Malignant HTN is a severe, rapidly progressive elevation in blood pressure that causes damage to the small arterioles in major organs All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 63 Hypertension cont’d Medical management Medications Lifestyle modification Diet Smoking cessation Stress management Treat underlying causes of secondary HTN All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 64 Arterial Aneurysm An aneurysm is an enlarged, dilated portion of an artery that exceeds 3 cm Aneurysms may be the result of arteriosclerosis, trauma, or a congenital defect Aortic aneurysms are most common in men in their 60s and 70s Other risk factors are smoking, hypertension, atherosclerosis, family history of aortic aneurysm, infarction, and trauma All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 65 Arterial Aneurysm cont’d Clinical Manifestations and Diagnostic Exams Palpating mass in the abdomen Chest pain Shortness of breath Dysphagia Pain in lower back or anus Diagnosed with CT scan, X-ray, Aortograph, MRI All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 66 Arterial Aneurysm cont’d Medical Management and Nursing Interventions Control hypertension Graft Removal of aneurysm The nurse should monitor patient status and report changes quickly Treat anxiety Treat pain Report sudden changes to the provider rapidly All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 67 Buerger’s Disease Thromboangiitis obliterans (Buerger’s disease) is an occlusive vascular condition in which the small- and medium-sized arteries become inflamed and thrombotic Most often affects men ages 25-40 who smoke Characterized by pain and sometimes ulceration There are no specific tests for this condition Treatment focuses mainly on modifying risk factors and stopping smoking Nursing interventions focus on managing risk factors and promoting circulation All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 68 Buerger’s disease All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 69 Raynaud’s Disease Caused by intermittent arterial spasms Raynaud’s is either primary or secondary Primary—the cause is not known and the condition is usually mild Secondary—when symptoms occur as a result of other conditions The patient typically complains of cold hands and feet and may have discoloration Medical management is aimed at prevention Nursing interventions focus on promoting comfort and preventing the disease All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 70 Thrombophlebitis Inflammation of the vein with formation of a thrombus Pain and edema occur when the vein is occluded Active dorsiflexion of the foot may result in calf pain Diagnosed via ultrasound Treatment is anticoagulant therapy Nursing interventions are aimed at controlling pain and administering prescribed medications All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 71 Varicose Veins Tortuous, dilated veins with incompetent valves Poor posture, prolonged standing, and constrictive clothing are risk factors Often the only symptom is the appearance of darkened veins on the patient’s legs Patient should be assessed for predisposing factors and varicosities Controlled with elastic stockings, rest periods, and leg elevation Sclerotherapy Nursing interventions focus on care of the patient after a surgical procedure All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 72 Stasis Ulcer Ulcers occur from chronic deep vein insufficiency and stasis of blood in the venous system of the leg Patient may report varying levels of pain Obvious stasis ulcer on the leg Pedal pulses are present Diagnosis made via venography and ultrasound Management focuses on promoting wound healing and preventing infection Nursing interventions are aimed at promoting wound healing and providing patient education All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 73 4 stages of a CVA: cardiovascular accident All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 74 Stages of CVA All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 75 The end All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 76
