Last updated on May 17th, 2022 at 10:12 am
Pancreatitis Nursing Care Plans Diagnosis and Interventions
Pancreatitis NCLEX Review and Nursing Care Plans
Pancreatitis is an inflammatory condition affecting the pancreas. The pancreas is an organ that is tucked behind the stomach. It releases enzymes that aid in digestion and regulates the body’s glucose levels through the function of the hormone insulin. Pancreatitis is usually acute, but it can also develop into a chronic disease. Treatment options will vary depending on the severity and type of pancreatitis.
Types of Pancreatitis
Pancreatitis is generally divided into two stages: Acute and Chronic. However, there is another type called necrotizing pancreatitis, but this condition usually manifests as a result of acute pancreatitis.
- Acute Pancreatitis (AP). Patients with acute type have to be treated promptly within a week, while severe cases require more extended treatment. There are varying types of treatment for this condition, and it depends on the patient’s type or stage. Acute pancreatitis usually happens in individuals who have gastrointestinal issues. It accounts for most hospital admissions yearly and requires extensive support to treat. The onset of this condition comes on suddenly, with the highest prevalence in adults than in children. Moreover, its treatment varies depending on its subtype: mild and severe. The most common causes of this disease in adults are gallstones and alcohol consumption. On the other hand, elevated triglyceride (TAG) and drugs can cause an attack. If not treated promptly and the individual is predisposed to an unhealthy lifestyle (e.g., smoking and heavy alcohol drinking), they are more prone to develop chronic pancreatitis.
There are three classifications of acute pancreatitis:
- Mild – without organ failure or other local or systemic complications. Typically last for days.
- Moderate – transient organ failure that is reversible within 48 hours, with the presence of local or systemic complications. Typically last for days.
- Severe – characterized by persistent organ/s failure, which typically lasts a few weeks. It typically begins with the respiratory system, compromising the air sacs and leading to difficulty breathing.
2. Interstitial edematous pancreatitis. This type can be classified as AP and is characterized by pancreatic enlargement or localized swelling resulting from inflammatory edema. This usually resolves during the first week of disease onset.
- Necrotizing pancreatitis. If acute pancreatitis is left unmanaged or untreated, it can result in a more severe complication–necrotizing pancreatitis, which commonly progresses into gland necrosis or cell death. Also, this condition significantly increases the risk of morbidity and mortality; hence, suspected cases usually require a series of diagnostic tests.
3. Chronic pancreatitis (CP). This type usually persists for more extended periods and then reappears. It is defined by persistent inflammation that does not subside or improve, resulting in irreversible damage (e.g., scar tissue formation, fibrosis, and calcification). If the pancreatic cells are damaged, the insulin-producing cells (Beta cells) are also harmed, resulting in diabetes in the worst-case scenario.
Numerous physiological factors can contribute to this, but alcoholism is the most prevalent. It works by altering the composition of pancreatic proteins produced, leading to the development of protein plugs.
Signs and Symptoms of Pancreatitis
The following are symptoms of acute pancreatitis:
- Fever
- Nausea
- Vomiting
- Tachycardia
- Upper abdominal pain that comes on gradually or suddenly
- Back pain
- Bloating
- Sweating
Patients with CP may also experience abdominal pain, vomiting, and nausea. The following signs and symptoms may also be present:
- Hyperglycemia
- Steatorrhea
- Jaundice
- Steady weight loss
- Upper abdominal pain with radiation in the back
- Back pain that is spreading
- Steatorrhea
Causes of Pancreatitis
Alcohol and gallstones are the two most common causes of pancreatitis. About two-thirds of those who suffer from this illness are in this cohort.
- Gallstones. These are solid lumps that resemble pebbles in size and shape. It is synthesized from bile, a digestive fluid. Both the pancreas and gallbladder share a common duct. The pancreas’ digesting enzymes and other substances from the common bile duct cannot be discharged into the duodenum when a large gallstone completely plugs the pancreatic duct. Blockage of the pancreatic duct results in inflammation due to the buildup of substances.
- Alcohol consumption. CP commonly manifests in patients with long-term alcohol use. The oxidative and non-oxidative processes lead to the formation of a reactive metabolic product called acetaldehyde which causes damage to acinar cells. In addition, alcohol prematurely activates trypsinogen and digestive enzymes in the acinar cells.
- Medications
- Trauma
- Cystic fibrosis
- Infections
- Family history
- Abdominal surgery
- Pancreatic cancer
- High triglyceride levels (hypertriglyceridemia)
Risk Factors to Pancreatitis
- Alcohol dependence (daily consumption of more than two units)
- Obesity
- Smoking
- Family history
Complications of Pancreatitis
- Respiratory complications. AP can induce chemical changes in the body that compromise respiratory function. Additionally, it causes pulmonary complications, such as acute respiratory distress, atelectasis, and hypoxia.
- Acute renal failure. Patients may require dialysis treatment in severe and long-lasting renal failure caused by AP.
- Diabetes. Most CP patients develop diabetes due to the damage or destruction of insulin-producing cells (islet cells). Insulin is a hormone that helps to regulate blood sugar levels, and if the amount of insulin in the bloodstream declines, hyperglycemia can occur.
- Pseudocyst. Cyst-like pockets can develop when the pancreas is inflamed. Because of these small collections of tissues, localized fluid builds up. A ruptured pseudocyst can induce internal hemorrhage and infection.
- Malnutrition. A decrease in the number of enzymes the pancreas produces to break down and utilize the nutrients in the diet can be caused by either AP or CP. Due to malabsorption, the lack of nutrient retention can cause malnutrition and steady weight loss.
- Infection. The risk of infection is increased when the patient has AP. Treatment for this condition may include surgery to remove infected tissue. On the other hand, pancreatic infections are generally reported in patients with necrotizing pancreatitis. Pathogenic bacteria may enter the hematogenous route, lymphatics, or transmural migration.
- Pancreatic Cancer. CP can become cancerous if left unmanaged. It is more likely since there is long-term inflammation of the pancreas.
Diagnosis of Pancreatitis
The handling physician may order multiple diagnostic tests to ascertain and corroborate the presence of pancreatitis. Primary tests include:
- Serum Amylase
- Serum Lipase
Both of which are elevated in patients suffering from this condition. On the other hand, the physician may order more baseline investigations; these include:
- Blood glucose
- Electrolyte
- Urea
- Arterial blood gases (ABGs)
Acute pancreatitis can be diagnosed by its presentation; thus, radiologic examinations are beneficial for visualizing the pancreas’ anatomic features. Moreover, it confirms and detects inflammatory processes and obtains information about the biliary and pancreatic ducts. Traditional modalities include visualization of the abdomen.
- Ultrasound. Usually performed to visualize the presence of gall stones, pancreatic swelling, peripancreatic fluid accumulation, and necrosis.
- Computed tomography. While this is not commonly done to identify AP, it effectively detects clinical or physiological degeneration.
- Transabdominal ultrasound. Due to the inability of this test to determine the extent of necrosis, it is less sensitive and less effective for visualization. In emergency situations, this may be necessary to exclude off cholelithiasis as an etiology of pancreatitis.
- X-ray. It allows visualization of the abdomen to exclude gastroduodenal perforation.
- Magnetic resonance imaging. This non-invasive approach visualizes the pancreatic parenchyma, revealing where inflammation and fluid collection occurs.
Some additional tests include:
- Pancreatic function test. Secretin stimulation test is another name for this diagnostic procedure. The handling physician inserts a tube into the nose or mouth until it reaches the small intestine. Samples of fluid will be taken through the tube inserted into your vein and secretin injected.
- Assessment of severity. Before treatment can begin, an assessment of the classification of the disease can predict the level of care and intervention needed.
- Fecal tests. The presence of oily stools with a characteristic foul odor (steatorrhea) may reveal gastrointestinal problems. Due to the fact that people with this condition have difficulty digesting fats, an increase in fat excretion through the feces is a risk factor for worsening pancreatitis.
Treatment of Pancreatitis
- Hospitalization. Supportive care for AP and CP patients is mainly provided in the hospital setting. Since the pancreas is a critical contributor to the body’s digestive processes, pain control, intubation, and volume replacement may be necessary. During hospitalization, the patient may receive fluids and nourishment specially adjusted to their needs via intravenous fluid (IV) or through a tube that passes from the nose to the stomach. This is referred to as a nasogastric tube.
- Medications. Patients may benefit from pain relief medications to control the pain. Pancreatic enzyme supplements assist the body in breaking down and utilizing nutrients. Each meal is supplemented with the recommended dose. Take into consideration that supplementation should be done under the supervision of a healthcare professional.
- Enteral nutrition. Patients with this condition may require substantial protein and caloric intake; however, oral intake may be compromised due to pain. Poor pancreatic regeneration will be the outcome of increased nutrient losses. Nutritional therapy and care, on the other hand, will hasten healing time. In some cases, the tubings used for feeding may be displaced in the stomach.
- Surgery
- Total Pancreatectomy. When the pancreas is severely injured, it may be necessary to remove the entire pancreas in the most severe cases of chronic pancreatitis.
- Gallbladder surgery. The physician may recommend surgical removal of gallstones if it is the underlying cause of pancreatitis.
- Endoscopic retrograde cholangiopancreatography. This is a surgical procedure that removes the bile duct obstructions. A narrow tube is passed down to the throat, and the camera provides images of the digestive system. In rare cases, this procedure could lead to AP.
- Alcohol cessation. Alcohol dependence is one of the leading causes of pancreatitis. Patients with pancreatitis who continue to rely on alcohol may be advised to seek treatment for alcoholism by their doctor.
While AP is usually self-limiting, changing the patient’s dietary intake can help alleviate its signs and symptoms. The following are alternative treatments and home remedies to manage AP:
- Low-fat diet. A low-fat and balanced diet will aid the patient’s recovery from pancreatitis. Because the pancreas has been damaged, the patient’s intake of fats is controlled. Avoid fried food, red meat, sugary meals, sweetened beverages, caffeine, and full-fat dairy as much as possible.
- Lifestyle changes. It is essential to stop drinking and smoking to expedite the healing process. If assistance is needed, talk to the handling physician. Meanwhile, the most common cause of pancreatitis, Gallstones, can be avoided by eating a healthy, balanced diet and exercising regularly.
- Pain control measures. Nonpharmacologic pain relief measures are another way to manage this disease. These include progressive muscle relaxation exercises, meditation, acupuncture, and cognitive behavioral therapy. Slow, measured motions are the emphasis of these alternative treatments since these may help the patient redirect their attention away from discomfort or pain.
- Changes in medication. If a specific drug is found to be causing acute pancreatitis, the handling physician may cease the prescription and find a replacement.
- Management of local complications through the removal of necrotic exudates
Prevention of Pancreatitis
Pancreatitis may or may not be preventable, depending on the underlying cause. However, there are a few things to minimize the risk of acquiring or developing pancreatitis:
- Smoking and alcohol cessation
- Eating a balanced and low-fat diet
- Avoidance of sugary beverages and desserts
Nursing Diagnosis for Pancreatitis
Nursing Care Plan for Pancreatitis 1
Imbalanced Nutrition: Less Than the Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than the Body Requirements related to poor oral intake, secondary to pancreatitis, as evidenced by stable weight loss, lack of interest in food, impaired muscle tone, inadequate food consumption, intolerance to food, and reported changes in taste sensations.
Desired Outcomes:
- The patient will show a steady increase and improvement in weight with the normalization of laboratory readings
- The patient will exhibit no symptoms of malnourishment.
- The patient will exhibit ideal weight loss and maintain weight through behaviors and lifestyle modifications.
| Pancreatitis Nursing Interventions | Rationale |
| Evaluate the patient’s abdomen for distension, complaints of nausea, and auscultate for any bowel noises. | Gastric distension and ileus (atony of the large intestine) may be accompanied by reduced intestinal activity, leading to hypoactive or absent bowel sounds. Gastric aspiration (Nasogastric tube) can be discontinued when bowel sounds return, and symptoms subside. This procedure is typically performed if there is a vomiting problem as it eliminates air and fluid from the pancreas and allows it to heal. |
| Ascertain that the patient maintains proper oral hygiene. | Nasogastric intubation is a therapeutic procedure that can cause subjective distresses such as mouth breathing, thirst, and dry mouth. It is typically used to augment or feed patients with pancreatitis experiencing gastrointestinal complications. Furthermore, the skin becomes irritated and inflamed due to gastric aspiration. By ensuring that the patient maintains proper oral hygiene or rigorously cleans the area around the tube, the risk of infection and decreased skin integrity are minimized. |
| Examine the patient’s stool and take note of its appearance, foul odor, quantity, and frothy consistency. | Chronic pancreatitis-related malabsorption can result in steatorrhea, a state in which nutrients are unable to disperse or absorb. It is defined by the presence of excess fat in the stools, which typically occurs as a result of incomplete fat digestion. |
| If the patient’s diet is resumed, assist them in selecting nutritious meals and beverages that correspond to any dietary restrictions. | The patient’s dietary intake pattern may be poor in terms of meeting the requirements for tissue regeneration and recovery. Other times specific meals such as oily foods can cause distress or worsen the signs and symptoms associated with pancreatitis. Moreover, consuming large meals, alcohol, caffeine, foods that cause gas or flatulence, and smoking can all overstimulate the pancreas, resulting in the recurrence of symptoms. |
| Take note of the patient’s serum glucose. | Glucagon is secreted by A2 cells (pancreatic islets), gastric fundus, and duodenum A cells, whereas insulin is secreted by pancreatic islet beta cells. Both of these hormones are necessary for blood sugar regulation. Because the pancreas cannot normally function, it initiates the release of excess glucagon and dramatically reduces insulin, resulting in high blood sugar levels. Hyperglycemia is another prevalent cause of pancreatitis; hence the association between the two should be observed because it may result in a more severe complication. |
| Observe the patient for signs and symptoms of thirst, frequent urination, changes in mentation, and visual acuity. Investigate reports of pain and metabolic stress. | Indicates developing hyperglycemia as a result of injured beta cells, resulting in decreased insulin secretion and increased glucagon release. |
Nursing Care Plan for Pancreatitis 2
Nausea
Nursing Diagnosis: Nausea related to blockage of pancreatic ducts, secondary to pancreatitis, as evidenced by gagging sensation, vomiting, abdominal pain, bad or sour taste on the mouth, and increased swallowing
Desired Outcomes:
- The patient will report decreased or absence of nausea.
- The patient will exhibit lifestyle changes that could help alleviate nausea.
| Pancreatitis Nursing Interventions | Rationale |
| Assess the cause of nausea. | The appropriate evaluation of the patient’s nausea can aid in determining the choice of intervention. Nausea is frequent in people with chronic pancreatitis due to difficulty with fat breakdown. It disrupts the body’s digestion and nutritional status; hence, it is critical to determine the underlying cause of nausea. |
| Ensure that the patient has easy access to a kidney dish or an emesis basin. | The sensation of vomiting often goes hand in hand with nausea. Ensure that the emesis basin is out of eyesight but easily accessible for patients with psychogenic nausea. |
| Maintain enough ventilation in the patient’s room or assist him/her with non-invasive ventilation. | Patients with CP may suffer from nausea and respiratory dysfunction; hence, ventilation is usually recommended to improve oxygenation. Having a well-ventilated room or a close fan helps improve indoor air quality and deter the risk of complications such as mechanical injury (as a result of dizziness), respiratory irritations, and nausea. |
| Encourage the use of nonpharmacological nausea control measures such as:Cognitive behavioral therapy or CBT techniquesProgressive Muscle relaxationRelaxation techniques (guided imagery, music therapy)Refocusing | Nausea and upset stomach can be relieved by practicing relaxation techniques. Although these methods have helped alleviate the symptoms associated with nausea, they must be employed before it ever arises. Moreover, these methods can contribute to pain alleviation related to pancreatitis or its underlying causes, such as gallbladder stones. |
| Support the patient before he/she undergoes diagnostic testing. | A variety of diagnostic tests, including an abdominal CT scan, upper GI tract radiography, and ultrasound, are required to determine the cause/s of nausea. Additionally, anxiety may intensify or exacerbate nausea, as it is a natural reaction to stress or fear. |
| Promote bed rest, maintain a peaceful environment, and withhold fluid. | To decrease the patient’s anxiety nausea. Rest and restriction of food and fluid intake can help patients with AP recover from their symptoms until the pain and nausea have subsided. Moreover, pancreatic secretions and pain will be reduced as a result of decreased stimulation and abdominal pressure. |
| Keep the patient on a low-fat diet at all times. | One of the most common causes of pancreatitis is gallstones. Gagging and vomiting symptoms are also heightened by it. Nausea and vomiting can be avoided if the danger of gallstone formation is minimized. |
| Recommend cold application (cold compress) in the back of the neck. | To ease the symptoms of nausea. Since pancreatitis and nausea are usually intercorrelated with fever, the patient’s basal temperature may rise. If he/she is feeling a gagging sensation or sickness, cooling the back of the neck may be comforting. |
| Maintain an upright position for the patient when eating and for 1-2 hours following a meal. | Activity may exacerbate nausea. Additionally, resting flat on one’s back might induce stomach acids to rise, resulting in increased nausea. It is usually recommended to recline the upper body to prevent feeling nauseated. |
| Advise patient to abstain from foods and avoid smells that may induce nausea. | Nausea can be exacerbated by offensive odors that are too strong or persistent. In addition, it lessens the sensation of nausea and vomiting due to gastrointestinal stimulation. |
| Teach the patient how to properly take prescribed drugs. | The prescribed drugs are typically used to alleviate the symptoms of nausea. This will decrease the risk of dehydration and hypovolemia. |
Nursing Care Plan for Pancreatitis 3
Hyperthermia secondary to infective process of pancreatitis as evidenced by temperature of 38.5 degrees Celsius, rapid breathing, profuse sweating, and chills
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
| Pancreatitis Nursing Interventions | Rationales |
| Assess the patient’s vital signs at least every 4 hours. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Tylenol) administered. |
| Remove excessive clothing, blankets and linens. Adjust the room temperature. | To regulate the temperature of the environment and make it more comfortable for the patient. |
| Administer the prescribed antibiotic and anti-pyretic medications. | Use the antibiotic to treat bacterial infection (pancreatitis), which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. |
| Offer a tepid sponge bath. | To facilitate the body in cooling down and to provide comfort. |
| Elevate the head of the bed. | Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. |
Nursing Care Plan for Pancreatitis 4
Nursing Diagnosis: Acute Pain related to obstruction of pancreatic ducts secondary to acute pancreatitis as evidenced by pain score of 10 out of 10, verbalization of sharp abdominal pain, guarding sign on the abdomen, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
| Pancreatitis Nursing Interventions | Rationale |
| Administer prescribed pain medications. | To alleviate the symptoms of acute abdominal pain. Pain on the right upper quadrant of the abdomen suggests the involvement of the head of the pancreas, while left upper quadrant pain refers to the tail of the pancreas. Narcotic analgesics such as meperidine should be preferred over morphine, as the latter has a side effect of biliary pancreatic spasms. Antacids may be used in combination with analgesics in order to neutralize gastric acidity and reducing the production of pancreatic enzymes. |
| Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication. | To monitor effectiveness of medical treatment for the relief of abdominal pain. The time of monitoring of vital signs may depend on the peak time of the drug administered. |
| Elevate the head of the bed if the patient is short of breath. | To increase the oxygen level by allowing optimal lung expansion. |
| Place the patient in complete bed rest during severe episodes of pain. Perform relaxation techniques such as deep breathing exercises, guided imagery, and provision of distractions such as TV or radio. | To reduce gastrointestinal stimulations thereby decreasing pancreatic activity. |
Nursing Care Plan for Pancreatitis 5
Nursing Diagnosis: Deficient Knowledge related to new diagnosis of chronic pancreatitis as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”
Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of chronic pancreatitis and its management.
| Pancreatitis Nursing Interventions | Rationales |
| Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits)To address the patient’s cognition and mental status towards the new diagnosis of chronic pancreatitis and to help the patient overcome blocks to learning. | |
| Explain what pancreatitis is, its types (specifically chronic pancreatitis). Avoid using medical jargons and explain in layman’s terms. | To provide information on pancreatitis and its pathophysiology in the simplest way possible. |
| Educate the patient about lifestyle changes that can help manage chronic pancreatitis. Create a plan for Activities of Daily Living (ADLs) with the patient that involve alcohol avoidance, smoking cessation, dietary changes, and physical activity. | To help the patient avoid alcohol intake that may lead to preventing further damage to the pancreas. To encourage the patient to stop smoking, as nicotine is a stimulant for unnecessary gastric secretions and pancreatic activity. |
| Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to manage chronic pancreatitis. Ask the patient to repeat or demonstrate the self-administration details to you. | To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details. |
| Encourage the patient to continue following a low fat, bland diet with caffeine restrictions. Refer the patient to a dietitian as required. | To avoid overstimulation of the pancreas. To enable to patient to receive more information in managing diet through a dietitian. |
Nursing Care Plan for Pancreatitis 6
Nursing Diagnosis: Risk for Fluid Volume Deficit
Desired Outcome: The patient will demonstrate adequate hydration and balanced fluid volume
| Pancreatitis Nursing Interventions | Rationales |
| Assess vital signs, particularly blood pressure level. | Pancreatic ischemia may lead to third space fluid shifting, which may lower blood pressure levels and put the patient at risk for hypotensive episodes. |
| Commence a fluid balance chart, monitoring the input and output of the patient. Include episodes of vomiting, gastric suctioning, and other gastric losses in the I/O charting. | To monitor patient’s fluid volume accurately. |
| Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously. Encourage oral fluid intake of at least 2000 mL per day if not contraindicated. | To replenish the fluids and electrolytes lost from vomiting or other gastric losses, and to promote better blood circulation around the body. |
| Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside. | To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. |
| Prepare the patient to undergo peritoneal lavage, if indicated. | To provide a rapid treatment of metabolic abnormalities by removing pancreatic enzymes and toxic chemicals in acute pancreatitis. |
Nursing Care Plan for Pancreatitis 7
Nursing Diagnosis: Risk for Infection
Desired Outcome: The patient will be able to avoid the development of an infection.
| Pancreatitis Nursing Interventions | Rationales |
| Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress and cholestatic jaundice. | Sepsis or infection of the blood may be evidenced by fever accompanied by cholestatic jaundice and respiratory distress. |
| Perform a focused assessment on the abdominal region, particularly checking for abdominal pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness. | Peritonitis is a serious complication of pancreatitis. It is evidenced by abdominal pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness. |
| Obtain a sample for culture, such as pancreatic enzyme, blood, urine, or sputum. | To identify the presence of an infection and its causative agent. |
| Teach the patient how to perform proper hand hygiene. | To maintain patient safety and reduce the risk for cross contamination. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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