Critical Analysis of Nursing Intervention: CPAP - Case Study Example

Critical Analysis of Nursing Intervention: CPAP Introduction Recognizing sick and more dependent persons and increasing the level of care and attention to them is known as high dependency care (Sheppard & Wright, 2000). In this type of care, the patients receive more support from the nurses, doctors and other medical professionals in the form of monitoring and treatment. The multidisciplinary team which takes care of the high dependency patient is more trained, knowledgeable and specialized. Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. The role is further enhanced in high dependency care units where patients need continuous monitoring and frequent evaluation and interventions (Nettina, 2006). In these patients, the nurses are expected to do some procedures and administer some interventions on their own like intravenous access, venous blood sampling, arterial blood sampling, intubation and insertion of endotracheal tube, bag and mask ventilation, enema and continuous atmospheric positive pressure ventilation or CPAP and many other procedures (Nettina, 2006). To enact in the most appropriate way in the scenario of intensive care unit, nurses must have a sound knowledge and possess adequate skills related to intervention. Critical analysis of a case enhances knowledge and also facilitates learning (Nettina, 2006). In this essay, critical evaluation of administration of continuous positive airway pressure or CPAP by nurses in a patient with acure respiratory distress admitted to intensive care unit will be elaborated to ascertain the role of critical care nurse in the managment of patients with respiratory failure. CPAP is a type of non-invasive ventilation that provides positive ventilation in both inspiratory and expiratory phases. It is a very useful intervention that can be administered by simple means in patients suffering from mild to moderate respiratory failure subsequent to conditions like pneumonia, Adult Respiratory Distress Syndrome, cardiogenic pulmonary edema and pneumonia (National Health Service, 2005). The complications of this procedure are also minimal. In this essay, administration of CPAP will be discussed with reference to management of mild Adult Respiratory Distress Syndrome. The discussion will involve an overview of the case scenario, disease process, details of the intervention, critical analysis of the intervention with reference to the case, review of the outcome with reference to intervention and implications for future use of the treatment with reference to the condition. Case scenario The case selected for study is about a 35 year old patient by name James admitted to the high dependency unit with mild ARDS. James was brought to the Emergency department on a Saturday evening following sudden onset of breathlessness. He was suffering from fever, cold and cough from 2 days prior to that. On examination James was breathless, and had increased work of breathing. He appeared slightly pale. Pulse rate was 100 per minute, respiratory rate 30 per minute, blood pressure 140/90mmHg and temperature 100 degree Fahrenheit. Saturations were 90 percent. Examination of the chest revealed good air entry on both sides with diffuse crepitations but no rhonchi. The patient was conscious, alert and oriented, but appeared tired. Other systems examination was unremarkable. An urgent chest X-ray revealed diffuse infiltrates distributed all over the lungs indicative of ARDS. Arterial blood gas analysis or ABG revealed mild hypoxemia and mild hypocapnia. pH was 7.32, PaO2 was 80mmHg and PaCO2 was 30mmHg. ECHO showed normal function and structure of the heart with good ejection fraction. Based on these findings, a diagnosis of early Acute Respiratory Distress Syndrome or ARDS was made and the patient was admitted to the high dependency ward. In the High Dependency Care Unit, intravenous line was initiatied and blood samples were sent for complete blood picture, blood culture, blood sugar and serum electrolytes. IV Augmentin was started for broad spectrum antibiotic coverage while awaiting culture reports. Intravenous fluids were provided based on the requirements of the patient. Oxygen was provided through re-breathable mask @ 2 litres per minute. The patient was monitored continuously for changes in saturations, pulse rate, respiratory rate, blood pressure and general condition. Following 12 hours of observation in the unit, it was noted that the patient was finding it difficult to breathe. The oxygen requirements increased and repeat ABG was suggestive was pH of 7.30, PaO2 of 80 and PaCO2 of 26mmHg. The patient also expressed tiredness. Then the patient was put on continuous positive atmospheric pressure ventilation or CPAP after discussing evidence-based criteria to initiate this intervention. The patient was kept in the High Dependency Unit for 4 days during which time he received CPAP ventilation for 3 days and after monitoring for another day, he was shifted to the ward. Treatment of James was enhanced by coordination amongst members of an interdisciplinary team which involved physician, intensivist, nurse, physiotherapist and respiratory specialist. Critical thinking and analysis The clinical disease Acute Respiratory Distress Syndrome, also known as adult respiratory distress syndome (ARDS), is a parenchymal lung injury which is diffuse resulting in severe respiratory distress and hypoxemic respiratory failure. The pulmonary edema is non-cardiogenic in origin. The diagnosis is mainly made on clinical grounds. The American-European Consensus Conference has set forth the following criteria to make a clinical diagnosis of ARDS (Conrad, 2005): acute onset, bilateral infiltrates, pulmonary artery wedge pressure less than 19 mm Hg (or no clinical signs of congestive heart failure) and PaO2/FIO2 ratio less than 200 (ARDS) or less than 300 (acute lung injury) (Conrad, 2005). ARDS is predisposed by many conditions like infections, aspiration of either gastric contents or water, inhalation of toxic or hot fumes, overdose of drugs like heroin, systemic inflammatory response syndrome and idiopathic. The hallmark pathology in this condition is diffuse alveolar damage. There is also damage to the lung capillary endothelium (Harman, & Walia, 2006). This leads to loss of integrity of the alveolar-capillary barrier. There is transudation of protein-rich fluid across the barrier resulting in pulmonary edema. Intrapulmonary shunting occurs leading to hypoxemia (Conrad, 2005). ARDS is potentially fatal disease. Mortality rate averages to 60% (Conrad, 2005). Many complications can occur during the course of the disease. These include multiple organ failure, superinfection with bacteria, permanent lung disease like pulmonary fibrosis or restricted lung disease, and even death. Complications due to treatment like oxygen toxicity and barotrauma can also occur. Most of the patients succumb to sepsis or multiple organ failure (Conrad, 2005). Nursing assessment The obvious clinical symptom in ARDS is dyspnea as in James. The patients present with labored breathing, tachypnea, increased work of breathing and hyperventilation. James presented with tachpnea, tiredness and increased work of breathing. Due to hypoxemia there may be cyanosis, agitation and eventually obtundation. However, the disease process was not severe enough in James to have caused these symptoms. Tachycardia is usually present (Conrad, 2005) as was evident even in James. Auscultation of lungs reveals scattered crackles due to diffuse alveolar damage (Conrad, 2005) and this was significant in James. Although in most patients, X-ray chest reveals findings only in later stages, in James, diffuse infiltrates in the lungs were evident even in initial stages. X-ray in early stages may also be useful in detecting the predisposing factor like pneumonia. In James, the X-ray findings ruled out pneumonia, but showed evidence of diffuse edema, although the findings were not very clear. Other investigations like CT Scan and MRI are not of much value (Conrad, 2005) and hence were not performed in the patient. When in doubt, ECHO may be helpful in ruling out cardiogenic cause of edema (Conrad, 2005). In James, ECHO was normal. Hemodynamic monitoring with the pulmonary catheter is often helpful in separating cardiogenic from noncardiogenic pulmonary edema (Harman, & Walia, 2006). However, this was not done in James as it was not required. Blood culture, complete blood picture, sputum culture and broncho-alveolar lavage culture are useful to decide upon the cause and choice of antibiotics (Conrad, 2005). In James, blood culture and complete blood picture were done. Blood culture was normal. Complete blood picture was suggestive of leukocytosis with lymphocytic predominance. Nursing diagnosis, interventions and management The nursing diagnosis at the time of admission of the patient was poor oxygenation and acute respiratory failure for which ABG was done and the patient was admitted to the High Dependency Unit where he was monitored and provided oxygen therapy. The nurses noted changes suggestive of increased work of breathing, increased breathing rate, diaphoresis, intercostal muscle retraction, fatigue and pulmonary edema (Nettina, 2006). The nurses also assessed level of consiousness, ability to tolerate increased work of breathing, signs of hypoxemia and hypercapnia (Nettina, 2006). The nursing diagnoses were impaired gas exchange. After 12 hours, in view of persistent and worsening respiratory failure, as evident by clinical examination, ABG and increased difficulty of breathing, he was started on CPAP. The patient was positioned in semi-recumbent position and given chest physical therapy to mobilise secretions. Nurses were aware of risk of oxygen toxicity and gave only as much oxygen as required guided by saturations monitor. Fluid balance was monitored using an input-output chart and urine specific gravity. Prior to initiation of CPAP, the nurses assessed the level of consciousness of the patient and the gag reflex. This is because, CPAP may lead to aspiration if the patient is unable to breathe spontaneously and protect his airway (Nettina, 2006). The nurses showed the mask to the patient and explained him the procedure. A nasogastric tube was inserted based on the clinician order. The nurses set the desired oxygen concentration of oxygen blender and adjusted the flow rate in such a way that it met the inspiratory demands of the patient. The mask was placed on the face of the patient, the head strap was adjusted and the mask cushion was inflated to ensure tight seal. It is important to maintain airtight seal for appropriate delivery of CPAP (Nettina, 2006). Head straps and inflatable cushions help sealing in difficult areas like nose and chin with comfort (Nettina, 2006). Care was organised in such a way that the mask was removed as infrequently as possible. After initiation of CPAP, the nurses performed frequent ABGs. They reviewed the hemodynamic status and level of consciousness frequently. They also assessed the patency of nasogastric tube frequently. Any rise in PaCO2 levels was reported immediately. The functioning and the comfort of the patient was evaluated every four hours. These monitoring aspects provide an objective documentation of patient response (Conrad, 2005). CPAP may cause increased work of breathing making the patient feel more tired and cause inability to maintain ventilation. Such situations warrant the need to intubate and mechanically ventilate (Nettina, 2006). The NG tube may become obstructed and cause gastric distension and aspiration. A patient with ARDS must be immediately admitted to the intensive care unit and an ABG done immediately to assess the severity of the condition and to decide upon intubation and mechanical ventilation (Conrad, 2005). Basics of emergency like airway, breathing and circulation must be taken care of. The patient must be put on continuous pulse oximetry and cardiac monitoring. ABG must be done at regular intervals. James was managed accordingly in the high Dependency unit. In refractory hypoxemia or marked respiratory distress, endotracheal intubation and ventilation must be started (Conrad, 2005). However, recent reports have pointed to the benefits of using non-invasive ventilation like CPAP for delivering high PEEP in patients with mild ARDS. This is because, in early stages of ARDS, the patient is not very tired, is conscious and oriented and thus is able to breathe on his own. Thus in James CPA was initiated after lack of improvement following 12 hours of treatment. CPAP administration in this stage prevents intubation and mechanical ventilation and enhances fast recovery (Schönhofer et al, 2008). Descriptive overview of CPAP Continuous positive airway pressure or CPAP is a type of non-invasive ventilation which is designed to produce positive ventilation to the patient both during inspiration and expiration (Keen, 2000). It is a simple, yet gentle and inexpensive mode of respiratory system that helps prevent collapse of alveoli, thus increasing the functional residual capacity of lungs (National Health Service, 2005). Continuous Positive Airway Pressure (CPAP) is “the maintenance of a positive pressure throughout the whole respiratory cycle (inspiration and expiration), when breathing spontaneously” (National Health Service, 2005). The system of CPAP is totally closed incorporating a tightly fitting nasal mask or face mask and a valve whose pressure is usually between 5-10cm H2O against which the patient on CPAP breathes. The valve is a low resistance valve. Administration of CPAP can be done either with the help of CPAP unit or through non-invasive functionality of ventilator (Keen, 2000). CPAP machine acts by delivering compressed atmospheric air to a nasal pillow through a hose at a prescribed pressure determined by the physician. There are many techniques through which CPAP needs to be administered. They are nasal, nasopharygngeal, facemask with seal, headbox with seal and endotracheal (Sarma, 2007). The components in the system of CPAP are gas source which provides continuous supply of air or oxygen or a combination of both in a warm humidified form, a pressure generator that creates positive pressure in the circuit and a patient delivery system that connects CPAP circuit to the airway of the patient. The pressure sources of CPAP are of two types, the continuous flow devices and variable flow devices. The delivery devices of CPAP are nasal prongs, long nasopharyngeal prongs, nasal cannulae and nasal masks (Sankar et al, 2008). Indications for CPAP use CPAP delivers a therapy which is between conventional oxygen therapy and controlled ventilation through intubation and mechanical ventilation with the help of a ventilator. The purpose of delivering CPAP is to prevent atelectasis, reduce the work of breathing resulting due to the pathological condition of the disease and also to increase oxygenation. CPAP also allows normalisation of the functional residual capcity that decreases in diseased lungs (National Health Service, 2005). CPAP is indicated in many medical condition in adults, chlidren and new born. The therapy is appropirate for hypoxic patients who are not yet exhauseted and are in a position to breathe. Some of the condtions in whch CPAP may be useful are infective exacerbation of chronic obstuctive pulmonary disease, pneumonia, mild to moderate adult respiratory distress syndrome, fibrotic lung disease and cardiogenic pulmonary edema. other indications for CPAP therapy are hypoxemia following extubation and weaning from positive end expiratory pressure (National Health Service, 2005). Contraindications There are many contraindications for the use of CPAP therapy and physicans and nurses administering CPAP therapy must be aware of these and rule of these conditions befroe initiaing CPAP. These include untreated pneumothorax, recurrent pneumothorax, severe post operative pulmonary air leak, epistaxis, central apnoea, elevated intracranial pressure, over distension of lungs, recent surgery in the ear, nose or throat, basillar skull fracture because of the risk of pneumocephalus, unstable facial fractures or facila burns and lacerations. In certain consitions, CPAP is not contraindicated, but must be administered with caution. Some such conditions are hypovolemia, hypotension, asthma, chronic obstructive pulmonary disease, bronchial tumor, recent esaphageal anatamosis, reduced conscious level and hypercapnia and or ventilation (National Health Service, 2005). Critical analysis of CPAP intervention in the patient Nurses play an important role in administering CPAP intervention to a patient. In case of James on all shifts, nurses who took charge of care for him, checked the CPAP circuit soon in the beginning of the shift itself. The nurses checked the CPAP system for proper functioning. They looked for maintenance of positive pressure, absence of circuit leaks, presence of adequate inspiratory air flow and delivery of the prescribed FiO2. The Peak End-Expiratory Pressure or PEEP was initially set at 7. Gradually, based on clinical improvement, the PEEP was brought down to 4 in less than 48 hours. The FiO2 was initially started at 1 and then was gradually decreased to 0.7 over 24 hours. Then it was decreased to 0.4 in 48 hours time frame from the time of admission. All these decisions were made after consulting and discussing with the physician. The application and monitoring of a patient on CPAP must be guided by validated indications and local expertise of the nursing staff to minimise the risk of complications (Sarasin and Jolliet, 2005). James was always under the supervision of a nurse and was never left alone. Universal precautions were followed and no piece of equipment was shared between James and other patients. The patient received intermittent suctioning though the CPAP tube. The nurse involved James wife and mother in the planning and exucuting of nursing care. All procedures and activities on James were performed only after expaling James about them. A day and night rhythm was established and the nurse provided a bood and pen as a suitable mode of communication. James was monitored closely while on CPAP. The nurse checked him visually every 30 minutes and noted the respiratory rate and effot, saturations and evaluated for presence of nausea and vomiting. Hourly, his pulse rate and rhythm, manual blood pressure, perfusion and normal fucntioning of the humidification system were noted. Second hourly checking of condition of conjunctivae and the skin under and around the mask and rubber securing were noted. Abdominal distension and the need for stomach decompression were evalauted every four hours. On one occasion there was abdominal distension which was decompressed using a Ryles tube after consultation with the physician. The water level of the humidification unit was checked every hour. Response to treatment was monitored using ABG. The nurse was aware of various compliccations of CPAP intervention and kept a high index of suspicion for the complications. Some of the complications include necrosis of the skin around the nose and chin (McCoskey and Meritt, 2008), insufflation of the stomach and aspiration of the stomach contents in the lungs, mask intolerance, mask leaks and rebreathing of carbondioxide which can be prevented by using appropriate expiratory valve (RPAH, 2006). Other complications which need to be looked for are barotrauma, sinusitis and conjunctivitis (McCoskey and Meritt, 2008). Though, ARDS needs to be managed with endotracheal intubation and positive pressure ventilation, there are some reports that Noninvasive positive pressure ventilation or NIPPV/CPAP during early ARDS prevents intubation (Rabitsch, Staudinger, Brugger et al, 1998 and Israel, Gross and Bomba, 1980). The therapeutic benefits of applying non-invasive ventilation like CPAP therapy for the treatment of acute and chronic respiratory failure is increasing leading to increased use of CPAP in patients with problems of oxygenation but not ventilation (Brigg, 1999). There is limited literature pertaining to the usefulness of NIPPV/CPAP in ARDS. Rocker et al (1999) reported that application of NIPPV through facemask in ARDS patients decreased the chances of intubation in 67 percent patients. Recent reports have proved the benefits of treating early stages of ARDS with CPAP. Chen et al (2003) studied the improvement of clinical signs and symptoms in patients with severe acute respiratory syndrome following NIPPV. The findings of their study prompted the researchers to employ NIPPV as a substitute to endotracheal ventilation in selected group of respiratory distress syndrome. Their study however showed that some patients who may improve with NIPPV may land up in intubation and mechanical ventilation. A study by Schonfer, Kunlen, Neumann et al (2008) revealed the CPAP is a useful mode of non-invasive ventilation in patients with acute lung injury. Chawla, Khilnani, Suri, et al (2006) reviewed literature pertaining to the use of NIPPV in ARDS and recommended that the use of NIPPV in ARDS patients must be applied with caution and only in ICU, guided by hemodynamical stability and close monitoring. In his study on the use of NIPPV in ARDS patients, Osborn (2003) reported that timely institution of NIPPV for ARDS patients in mild to moderate stages avoided intubation in more than 50 percent patients. According to Malhotra and Jindal (2005), in contrast to the beneficial effects of non-invasive positive pressure ventilation (NIPPV) in many types of respiratory failure like cardiogenic pulmonary edema and acute exacerbations of chronic obstructive pulmonary edema, the role of NIPPV in ARDS is unestablished, but institution of NIPPV in early stages may prevent endotracheal intubation and mechanical ventilation. In a study by Zhao, Zhang, Xu et al (2003), patients who were treated with CPAP in the initial stages of lung injury responed well to CPAP. However, these benefits were contradicted by a study by Delclaux, LHer, Alberti, et al (2000; cited in Agarwal, Reddy, Agarwal et al, 2006) who opined that administration of CPAP in early lung injury cases, neither increased the outcome nor decreased the chances of getting intubated. Agarwal et al (2006) conducted a meta-analysis of the benefits of NIPPV in the management of ARDS and opined that NNIV neither reduced the endotracheal intubation rate, nor improved the ICU survival rate. Thus there are conflicting reports about the benefits of CPAP in ARDS. Institution of CPAP therapy in James was guided by hemodynamic stability, ability to breathe and constant monitoring. Review of outcome James was admitted to the intensive care unit with a diagnosis of mild ARDS secondary to viral infection in a hemodynamically stable condition. The team of health professionals discussed about what mode of ventilation was to be provided for James. Based on the evidence-based literature, since James was hemodynamically stable and could breathe on his own, face-mask CPAP was initiated at a PEEP of 7.5 and FiO2 of 1 which was gradually decreased to PEEP 5 and FiO2 0.21 in 48 hours. On the fourth day of admission, he was removed off the CPAP. One day later he was transferred to the ward where IV antibiotics were continued. He remained stable for 2 days after which he was discharged. Early intervention with CPAP decreased the need for endotracheal intubation, hastened recovery and reduced the duration of stay in the hospital. Implications for future treatment Non-invasive ventilation in the form of CPAP is a useful mode of providing PEEP in patients in early stages of ARDS. This intervention in hemodynamically stable patients decreases the chances of intubation, prevents long duration of hospital stay and decreases cost to treatment. Further studies in the form of randomised control trials are warranted to give broader picture about the effectiveness of the intervention on the disease pathophysiology with respect to outcomes. Conclusion Through critical thinking and analysis, it is possible to gain overall knowledge about the subject because it involves research, evaluation of current practices and implications for future treatments. The nurses in the intensive care unit were guided by evidence based practice, unit protocols and research and this in turn provided a positive outcome to the patient. References Agarwal, R., Reddy, C., Aggarwal, A., et al (2006). Is there a role for noninvasive ventilation in acute respiratory distress syndrome? A meta-analysis. Respiratory Medicine, 100(12), 2235-2238 Brigg, C. (1999). The benefits of non-invasive ventilation and CPAP therapy. British Journal of Nursing, 8(20), 1355- 1361. Chawla, R., Khilnani, G.C., Suri, J.C., Ramakrishnan, N., Mani, R.K., Prayag, S., et al (2006). Guidelines for noninvasive ventilation in acute respiratory failure. Indian J Crit Care Med., 10, 117-47. Chen, H., Wang, X.P., Li, F., Yang, Q., Zhang, L.G., Du, J.X., et al . (2003). Evaluation of noninvasive positive pressure ventilation in treatment for patients with severe acute respiratory syndrome. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue, 15, 585-8. Conrad, S.A. (2005). Respiratory Distress Syndrome, Adult. Emedicine from WebMD. Retrieved on 28th October, 2009 from http://www.emedicine.com/emerg/topic503.htm Harman, E.M. & Walia, R. (2006). Acute Respiratory Distress Syndrome. Emedicine from WebMD. Retrieved on 28th October, 2009 from http://www.emedicine.com/med/TOPIC70.HTM Israel RH, Gross RA, Bomba PA.. (1980). Adult respiratory distress syndrome associated with acute nitrofurantoin toxicity. Successful treatment with continuous positive airway pressure. Respiration., 39(6):318-22. Keen, A. (2000). Continuous positive airway pressure (CPAP) in the intensive care unit--uses and implications for nursing management. Nurs Crit Care., 5(3):137-41. Malhotra, P., and Jindal, S.K. (2005). Does noninvasive ventilation work in ARDS? A case report and review of the current literature. Emergency Medicine Journal, 22, 745-746. Marshall, A., and Pittard, M. (1998). Nursing the patient receiving continuous positive airway pressure therapy. Aust Nurs J., 5(7), 27-30 McCoskey, L., and Meritt, L. (2008). Nursing Care Guidelines for Prevention of Nasal Breakdown in Neonates Receiving Nasal CPAP. Advances in Neonatal Care, 8(2), 116- 124. National Health Service. (2005). Guidelines for use fo CPAP systems in adults. Retrieved on 28th October, 2009 from http://www.ruh.nhs.uk/about/policies/documents/clinical_policies/blue_clinical/Blue_717_CPAP_Guidelines.pdf Nettina, S.M. (2006). Diabetes and related disorders. Lippincott Manual of Nursing Practice.,8th edn. Philadelphia: Kipincott Williams and Wilkins. Osborn, T.M. (2007). Noninvasive Positive Pressure Ventilation for ARDS. Crit Care Med., 35, 18-25. Rabitsch W, Staudinger T, Brugger SA, Reiter E, Keil F, Herold C. (1998). Successful management of adult respiratory distress syndrome (ARDS) after high-dose chemotherapy and peripheral blood progenitor cell rescue by non-invasive ventilatory support. Bone Marrow Transplant, 21(10), 1067-9. Rocker, G.M., MacKenzie, M.G., Williams, B., Logan, P.M. (1999). Noninvasive positive pressure ventilation: Successful outcome in patients with acute lung injury/ARDS. Chest, 115, 173-7. Royal Prince Alfred Hospital or RPAH .(2006). Intensive care Service Nursing Policy and Procedures. Retrieved on 28th October, 2009 from http://74.125.155.132/search?q=cache:T4-lViPWGIcJ:intensivecare.hsnet.nsw.gov.au/five/doc/cpap_V_rpa.pdf+cpap+nursing+care&cd=7&hl=en&ct=clnk&gl=in Sankar, M.J., Sankar, J., Agarwal, R., Paul, V., and Deorari, A. (2008). Protocol for Administering Continuous Positive Airway Pressure in Neonates. AIIMS. Sarasin FP, Jolliet P. (2005). Non invasive ventilation in emergency settings. Rev Med Suisse. 2005 Aug 10;1(29):1902-4 Sarma, A.K. (2007). Continuous positive Airway Pressure. Retrieved on 28th October, 2009 from http://74.125.155.132/search?q=cache:pwMK97L7zWsJ:www.pediatriconcall.com/fordoctor/Conference_abstracts/assampedicon2007/CPAP.pps+CPAP+nursing+care&cd=23&hl=en Schönhofer, B., Kuhlen, R., Neumann, P., Westhoff, M., Berndt, C., Sitter, H. (2008). Non-invasive ventilation as treatment for acute respiratory insufficiency. Essentials from the new S3 guidelines. Anaesthesist, 57(11), 1091-102. Sheppard, M. & Wright, M. eds. (2000) Principles and Practise of High Dependency Nursing. London: RCN Zhao, Z., Zhang, F., Xu, M., Huang, K., Zhong, W., Cai, W. (2003). Description and clinical treatment of an early outbreak of severe acute respiratory syndrome (SARS) in Guangzhou, PR China. J Med Microbiol., 52(Pt 8), 715-20. Read More