Holistic Assessment and Wound Healing Management for Congestive Cardiac Failure and Venus Leg Ulcer

This case study explores the holistic assessment and wound healing management of an individual with Congestive Cardiac Failure and Venus Leg Ulcer. It covers the patho-physiology of leg ulcers, nursing theories and models, and the nursing process. The study provides recommendations and references for further reading.

Holistic assessment and wound healing management
of an individual presenting with Congestive Cardiac
Failure and Venus Leg Ulcer following hospital
Discharged: Case Study
SID: 1511896
Word Count: 4800

Table of Contents
INTRODUCTION..........................................................................................................4
Patients Presentation....................................................................................................5
PATHO-PHYSIOLOGY LEG ULCER...........................................................................7
OVERVIEW OF NURSING THEORIES AND MODELS..............................................8
THE NURSING PROCESS........................................................................................14
ASSESSMENT...........................................................................................................14
PAIN ...........................................................................................................................16
Eating and Drinking....................................................................................................17
Mobility........................................................................................................................17
Planning......................................................................................................................18
Implementation...........................................................................................................20
Evaluation...................................................................................................................21
Conclusion..................................................................................................................22
Recommendation........................................................................................................23
REFERENCES...........................................................................................................24
APPENDIX 1...............................................................................................................26
APPENDIX 2...............................................................................................................26
APPENDIX 3...............................................................................................................27

INTRODUCTION
The venous leg ulcer is complicated and chronic disease which affects
most of the patient of 65 years old. The sensitive body of old people will easily
get in contact with these viruses that attached with their lives for long time. This
disease is prevalent in the UK among the people above the age of 60- 80 years
of old. The reason behind occurrence of the diseases in these peoples is weaker
immunity of old people and lack of white blood cells and the platelets in order
to fight against the dangerous diseases. According to posnett el at (2009),
CVLU affects 1- out of 2% of the UK population with over half having an
active ulcer.
The cost incurred in the treatment of this dangerous diseases estimated by
the National Health Service accounts for 5.3 billion each years as per the recent
study conducted in 2013-2014 in the UK. The study also reveals that the
patients suffering from this dangerous diseases will be counted all above the age
of 18 years as there is record of patients having this disease below 18 years.
The study reveals that the practised nurses are involved in treating patients in
order to avoid social isolation. The practice of the hospital starts that 18.6
million practices nurses and doctors are form part of this event, 1.09 million
doctors and paramedical staffs also visits communities and 3.4 million hospital
also gathers and treats outpatient visits through organising camps.
NHS Choices defines venous ulcers as wound which occur on skin of human
being due to improper functioning of venous valves. Moreover, the patients past
medical history (PMH) are also incorporated in the report which further helps in
as well as reason for planning, implementation and evaluation of patient care
with the use of appropriate model has also been explained.
The current essay will cover critical evaluation on report of care for patient. In this
regard, practical and theoretical elements regarding care planning as well as examination of
patient ailment has been explored under the report. Though, case study assignment related to
leg ulcers has been taken into account by taking specific situation of patient. In this manner,

report is completed in four steps such as nursing process as per the NMC (2010) along with
models of nursing as well as theories. It would be effective to provide holistic and and system
demonstration of care provided to patients and accordingly conclusion and evaluation have
been done. Furthermore, verbal consent has been taken for promotion of concordance,
respect difference in context of autonomy and maintaining dignity of patient.
Patients Presentation
Under the current study anonymity of patients has been maintained by complying
Data Protection Act 1998 and NMC 2015. At this juncture, pseudonym will be applied in
overall presentation.
The medical history of the patient will help the doctor in order to design
the best treatment for their patient. The history is essential in order to know the
allergies of the patient in order to prescribe accurate medicines to heal the
patients.
The current study is about Robert who is a 78year- old man who lives
alone in a one-bedroom flat. Mr Robert is active person who are educated and
are settled in their life as he is married and have two children. This person
belongs to the rich family who have status in the society and who speaks
English and all other languages. He worked in good company and enjoys higher
position in the business. The background of Mr Robert will not help him as they
are suffering from social isolation as different society members discriminate
them among different individuals.
He was admitted in the social home care with venous leg ulcer patients to
facilitate the patients. They feel more comfortable with all the individuals
suffering from the same disease and get motivated in terms of taking treatment.
Social isolation is the basic problem faced by these people which will be
reduced to relieve their pain. Robert will meet and greet all the individuals
suffering from identical diseases which reduces their mental distress level. The
mental stress will get reduced by focusing on other activities.

The loneliness of Robert will be minimized by breaking the social
isolated boundaries of their room. The consent of Robert has taken in verbal
form by talking face to face with the patient by asking various questions related
their problem and mental status by living in the society. The information
obtained regarding their prescribed medicines, allergy, reactions, blood and
sugar level will be very helpful in analyzing their nursing needs.
The medical findings of the doctor diagnosis suggest that Mr Robert has
past medical record of congestive cardiac failure. This current discovery of
evidences related to their diseases will help in planning perfect prescription for
providing perfect treatment to the patients.
Robert had a patient who has controlled analgesia which is also known as
PCA, a urinary catheter, which allows them to monitor the pain which is
worked as pain relief machine. The programmable machine and functioning has
intended that will not deliver overdose of the medication. It allows patient to
take a complete set of vital signs to monitor their own temperature, pulse,
respiration, blood pressure and oxygen saturation level.
The results related to their blood pressure and the medicines taken by them
reveals that the 140/80 blood pressure level which is under the control of the
doctors. The medicine taken by Robert for Blood pressure is LOSAR-50 mg
tablets to control their current blood pressure levels.

PATHO-PHYSIOLOGY LEG ULCER
The Venous ulcer is described by The Wound, Ostomy and Continence
Nurse Society (WOCN) as an open wound on the lower leg of venous origin or
ankle of person. The most common causes of VLS are chronic condition and
venous hypertension. The higher pressure of venous tends to become reason of
vales in the lower leg veins. However, vales perform the work to prevent back
flow of venous blood at the time of calf muscle congresses the veins to pump
the blood return to the heart (Viv as, Lev-Tov and Kirsner, 2016). Owing to
this, in case vales are incompetent then form of ulceration can be found in skin
as venous pooling and congestion leads to leak the blood into the tissue as
edema.
The venous ulcers is that disease which occurs due to lack of venous
valves in the body of an individual. This valves usually found in or around the
areas of leg near the muscles. The insufficient amount of venous valves will
affect the soft tissues of the legs that easily contracted with the attack of viruses.
The clotting of blood will raise the effect of this disease on the body of a
person.
The normal time taken by these diseases in the normal body of an
individual is around 6 weeks to get rid of this disease.
 Swollen ankles
 Darkening of skin
 Skin around the ulcer gets hard
 Feeling heaviness in the legs
The diagnosis of this disease as discovered that the assurance
will not be provided on the certainty of the ulcer. The existence of the
ulcer is due to disturbances created in the venous valves. The slow

movement of the blood properly to all the veins will contribute highly
in occurrence of these kinds of ulcers.
OVERVIEW OF NURSING THEORIES AND MODELS
There are different nursing theories and models which helps in rendering
good quality of services to its patients. The nursing staffs in the community
adopts systematic and holistic assessment of patients whereby health can be
recovered in relatively less time span. At this stage, Fawcett's concept of four
metaparadigms highlighted Nursing, environment and Health as well as person
(Lazarus and et. al., 2016). This concept shows that people who are getting
services from nursing staff can be individuals, families and communities. It is
well known fact that various dimension of nursing is associated with open,
interrelated and interactive way where nursing staff which has require to put
their efforts with informed choices. It proves to be effective in rendering good
quality of services to patients by following above mentioned dimensions.
Patient care- This approach focuses states that peoples which has explained
from the perspectives of the patients that they get feeling of home as their care
has been done by different peoples. An individual need intensive care from
nursing staff or therapists as well as doctors to fulfill their needs and objectives.
Patients are well treated ion home cares which helps all the patients to forget
their pains and enjoy with the nurses as they demand attention which is nor
provided to them in normal society and by their family members. They faced
issue related to language and cultural diversity which affect them as people
working in health care have different cultural backgrounds.
Giving importance to patients- Human beings are considered as the most
valued persons in care home where care workers require in giving respect to all
the patients by providing their services. In the given case Robert will be
informed related to their treatment as his consent will matter for care homes.

Taking consent of Robert will mentally prepare them in order to feel good
which in turn helps doctors to treat them without any consequences.
Creating friendly atmosphere- The healthy environment is another factor of
this model which includes set of values, mores, expectations and customers as
well as societal beliefs which is directly related to both service users and
providers. According to Petherick, Pickett and Cullum (2015).There are
different elements found under environmental considerations such as cultural,
historical, physical psycho social and development processes which tends to
provide peaceful environment to the patients. It tends to create good atmosphere
for services users and accordingly time and quality is managed and maintained
by care workers.
Health is another element of Meta paradigm as it is dynamic process that
stresses on two major points that is wellness and illness. It reflects that level of
health is sort of expression which is derived from mutual interactive process
between environment and humans.
The health of human being is directly related to feeling of caring by
another person which in turn motivate them to ensure their good health by
focusing upon various healthy standards. This also involves minimizing the
stress level of a person by focusing on their weaknesses in order to convert them
into their strengths.
Moreover, nursing practice is another most important element of
Metaparadigm. This is science of holistic health care which is guided through
set of choice, responsibility, and human freedom. The nursing practices uses
various logical analysis, researcher and theory of development which in turn
provides complete package of good quality of services.
According to Guest, Ayoub and Greaves (2015) Nursing staff uses
critical thinking and clinical judgment through which they can effectively treat
patients who are suffering from several kinds of disease. In this regard, caring

attitude is required for nursing staff through which they can understand the
exact need of users which in turn transform their actions in a correct way to
provide all the services in effective way. Van Gent and et. al., (2015) explained
that the nursing staff follow different approaches for rendering services to users
which consists of clinician, learner and leaders. However, they take the
responsibility to provide supportive, technologist and therapeutic care as per the
needs and expectations of the patients.
This is very basic level in which there are three main key components of
nursing model exists. One among the model includes different set of beliefs and
values which facilitates in carrying out various activities that are related to
prescribing medication. However, statement of the goals is framed under which
the model will represent the application of nursing practices which will helps in
achieving the same.
Similarly, Filkor and et. al., (2015) knowledge and skill are also acquired
by nursing staff in accordance with set objectives. A counter argument might be
that nursing models focus upon four central concepts which are already
explained. It has been found that nursing models include complex terms such as
care requisites, self-care deficit and health deviation affect learning to a great
extent. Furthermore, ineffective use of English language is the commonly found
barriers while interacting with various set of customers.
Roper-Logan-Tierney- The selected model for the study is of Roper-Logan-
Tierney (RLT) model of nursing which is based upon activities of living (AL).
This model at first developed in 1998 where basis was Nancy Roper 1976. This
RLT model is highly based upon activities of daily living under which is
generally used in UK. However, this model was updated in 2001 in accordance
with societal needs.
Roper-Logan-Tierney Model

Patients
care
Providing
independence
Enhancing
learning

The central focus of this model was on care of patients through which
nursing staff can easily implement the standards set by health care sector (Jozic
and et. al., 2015). It can be critically evaluated that care homes of UK uses such
kind of approaches just for checklist on admission. By using such kind of
approach, experts come to know that how life of a person has been changed due
to certain illness or admission to hospital. Though, it does not shed light on
increasing Independence or patients and quality of his life.
The activities of living covers in this model reflects that independence of
patient should be enhanced by putting efforts in the same direction (Vilela and
et. al., 2016). The basic purpose of implementation of this model is to judge
how an individual can improve own health and challenges. It also determines
how care patients can be ready to cope up with changes.
This aids to provide learning among patients and they follow the positive
behavior for recovering their health in relatively less time span. Furthermore,
Fox and et. al., 2015 stated that activities of living assesse exact independence
of individual and potential for independence on the range from complete
dependence to self-dependence to analyze the interview which form the basis
for increasing the self-dependence. At the same time, activities required to
compensate the dependence are also assessed for enhancing the learning of
sufferers towards health or maintaining the sound health. Roper's model is
considered most helpful as it shows that nurses should adopt such kind of
behavior in their care towards patients.
Lin and et. al., 2016 asserted that different activities covered under
activities of living are; maintaining a safe environment, communication,
breathing, elimination and washing & dressing. Along with that, controlling
temperature, mobilization and sleeping as well as working & playing are also
included which must be there at part of patients. These activities of living cover

all the important activities which are related to human being or patients so they
are referred at the time of admission of patient on a ward or service.
This is the major reason where older people are vulnerable to risk because
they need to be cared by others. Here, the first factors effective living activities
as biological reflects that how nutritional activities of a person different
between one who is having issue of diabetes and the one who is not having the
same. On the other hand, psychological factor shed light on spiritual beliefs and
ability to understand by patients.
For instance, if a person is educated enough then he will be sufficient
self-dependent in term of health promotion. In this manner, overall thinking,
believing, hoping and feeling are considered. It aids to determine influence of
psychological factor on dependence of patient as Judie (Harding, 2016).
Furthermore, Filkor and et. al., (2015) stated that socio-cultural factor
presents the expectations and values in accordance with actual health. This is
because all culture follows different set procedures and accordingly they tend to
behave in different manner. The eating habits and caring attitude is perceived by
individual based on culture.
However, expectations and assumptions of societies also matter under
which care workers will come to know that whether patient is self-dependent
(Marshall and et. al.,2015). On the other hand, environmental damages also
have direct impact on health of one person. Here, people do care of themselves
in case they are residing in an unfavorable environment. Moreover, last factor as
politico-economic also affect activities of living because of violent conflicts,
easy to access to benefits provided by government.

THE NURSING PROCESS
Accoridng to McCaughey, Cullum and Dumville (2015) Nursing process
is very important in health and social care as it support users to access good
quality of services. The basic aim of nursing is to focus upon identification of
the services which are required by users. It enables them to treat patients to
satisfy them as per their needs. Under this process staff at first give importance
to service users which proves to be effective meet their expectations in an
effectual manner. There are various characteristics of the overall nursing
process which is given as below: Dynamic- The nursing process has dynamic
nature under which all elements related to each other in the cyclical form . As
per the given scenario, Robert can effectively get treatment with the help of
nursing processes adopted by social health care homes. It aids in ensuring that
clinical decision making is used for resolving issues which are being faced by
patients. Another element is of association- It is well known fact that nursing
staff are directly associated with patients so they must be treated with respect.
Therefore, Robert will undergo the nursing process consists of four stages such
as assessment, planning and implementation and evaluation (APIE). It includes
all the standards of NMC such as competency standards for nursing staff and
foundation of nursing curriculum (Hampel-Kalthoff and et. al., 2015)
Cummings and Bennett (2012) explained that nursing diagnosis is not
likes normal medical under which diseases is identified rather its main aim is to
recognize the actual and potential health issues which forms disease.
ASSESSMENT
Nursing assignment refers to collection of information related to patient
by using suitable mode of communication. At this juncture, different procedures
can be applied such as observation, interview, past medical history and physical
examination. Along with that, data can also be collected through, inter-

professional team, family and friends. It proves to be effective to understand or
identify the problem which is being faced by patient and care provided to same.
For this purpose, information related to social, emotional and physical needs are
incorporated. Although, Robert was diagnosed as malnutritional. Immobile and
hyperventilation. Owing to this, aetiology is identified with the help of current
assignment which would also be helpful to render best care prior writing the
plan.
The commencement of assessment is very easy task which can be
completed by adopting effective procedure. Under this, confidentiality, dignity
and patient privacy have been maintained. At first nurse provided detail
information related to care plan along with her own introduction. She also
explained that information of Robert would be confidential and it will not be
shared with other party except multidisciplinary team. However, NMC code was
complied by taking verbal consent from patient in the light of treatment. Care
and intervention.
In this manner, Holistic assessment was conducted by ensuring clear
communication with patient. At this juncture, Robert was asked regarding any
kind of allergies for which nursing staff should take care. At the same time, all
daily routine activities were known so that staff can follow the living model of
patient effectively while rendering services.
The first step of nursing process is assessment under which important
information related to Robert will be collected. As per the given case scenario,
the information gathered regarding the medical history of Robert will be
presented in front of nurse so they can understand the present state of health.
This assessment can be done in several manners such as emergency assessment,
initial and risk as well as problem focused. Along with that, comparative
assessment is also done under which reassessment is done just after the original
one so that data can be compared with the standard guidelines of the nursing

process. Furthermore, comparative analysis aid to prepare baseline so that
extracted information regarding current causes of leg ulcers which facilitates the
doctor to provide necessary treatment for patients (Williams, 2015). On the
other hand, risk is assessed in the integrated manner under which specific
potential problem faced by Robert is identified effectively. However, problem
focused approach is used to identify the symptoms of the diseases and their
impact on the health conditions of a person. On the contrary, this stage the
doctors will predict the determined time of treatment in which this disease so
that Robert can get rid of this problem.
PAIN
The nursing diagnosis is also considered as effective approach under
which nurses uses critical thinking skills to review the collected data from the
assessment stage. However, nursing staff also analyzed the health condition data
of Robert for making appropriate care plan. At the same time, clinical judgment
skills are used to identify service users and their potential problems.
Anderson (2011) declared that assessment phase of nursing procedure
will also include data base regarding accurate information account the physical,
spiritual, social impact of the diseases etc. However, Robert had been assured
that all the collected information will be confidential where access will be
provided to team which is providing services for Robert. As per the assessment
of Robert, it has been found that Vital Signs for respiration was 29bpm with the
use of accessory muscles to breath. Total NEWS score was 11 where Oral
temperature was 37.6-degree C and Manual BP of Robert having issue of
Congestive Cardiac Failure (CCF). Furthermore, fluid balance lasts for 24 hours
negative 1,080mls but oral fluids is not taken by patients. Apart from this, status
of Chest X-ray was Pulmonary Odema and current medication is having
property of Oral Furosemide loop diuretic. Therefore, overall assessment
scenario of Robert shows that assessment will be done which helps nursing staff

in order to prepare the effective plan. However, nursing diagnosis is showing
that Hyperventilation, Hypoxia and Immobile which depicts that situation of
patient is damn critical.
Furthermore, A variety of pain rating scales such as the Numerical
Rating Scale and the Universal Pain Assessment Tool as well as the Visual
Analogue Scale can be used. In this regard, different signals associated with
non-verbal communication such as grimacing, gritting teeth and acute pain
occur to patients can be included.
Eating and Drinking
In the present assessment, nursing staff did not pay attention of major
cause of ulcer along with focus upon nourishment status and immobility.
Although, leg-ulcer are not growing because of nutrients. Furthermore, dietary
status is taken into account so that accordingly wound can be healed and related
complications can be prevented. Apart from this, malnutrition refers to
imbalance of energy and micro nutrients contribute towards measuring the
impact on patient. At this juncture, it is important to make Robert understand
the importance of proper diet for healing the wound. However, it is a common
fact that malnutrition is the most important aspect for patients over the age of
65. Owing to this, Robert's risk level of malnourishment was assessed by
applying malnutrition universal screening tool (MUST). Here, MUST reflected
greater than or equal to zero level of risk. It reflects that patient is at risk and
care was needed to heal the wound. The content of nutrients are increases to
heal the fresh wounds of all the patients. The patients of the venous ulcers will
be provided with high fiber and protein die to overcome their existing problem.
Mobility
According to Anderson (2012) generally individual or patients with less
immobility tend to develop ulceration in the areas of gaiter. It happens because

of improper function of the calf muscle pump. Here, life quality of person get
poorer because of chronic which might impaired mobility and movement of
Robert. At this juncture, degree of mobility of Robert was checked and it found
that some difficult is faced at the time of excising.
Here, nursing staff consider specific aspects such as specification of
patients' requirement. The assessment will also include other tools such as the
Applied Wound Management tool at the place of infection, and healing which is
plotted on continuum along with Time framework. This time framework
facilitates in taking care of patients effective in accordance with set standards.
Planning
The planning phase of nursing practices play important role which
reflects that long term goals or objectives are established. It serves as planned
nursing intervention where focus is laid on clear priorities and care plan.
Harding (2016) suggested that short term goals can also be established by
nursing staff just for the sake of motivation and self-esteem. It is very crucial to
involve evidence based approach, multidisciplinary team along with easy
accessibility to other members. This facilitates to cater requirement of patient
like Robert who is suffering from severe diseases which can be minimized by
the doctors and special care can be done by the nurses. According to the
provided scenario, nursing staff involved service users, family members for the
purpose making informed choices. However, care plan was communicated
among them in detail manner which in turn family members can also provide
their suggestions (Hampel-Kalthoff and et. al., 2015).Furthermore, collaboration
with patent is the most important phase at planning stage under which nursing
staff to convince the patient to follow the specific criteria of care and provide
support.
Owing to this, reason for complying the set standard will also be communicated
that how health will be recovered which is possible by conducting checkups on

monthly basis or weekly basis by the experts called upon on social service
users.
The medical diagnosis report states that the occupation therapists were referred
along with social services because Robert is living alone. The care plan of
Robert will involves family members and services users to make informed
choices. The care plan of patients shows that pulse to be 51-90 bpm within
duration of 2 hours’ ad respiration require to be 12-20 per 60 seconds but
without use of accessory muscle to breath with 2 hours. In addition to this,
dietitian and Nutritional support team was referred for eating and drinking of
patients.

Implementation
Implementation of care plan is the most important aspect as it supports
patient to recover his/her health. At this stage, nursing staff generally implement
the care plan in accordance with set criteria. The implementation of plan will be
done by monitoring the score on hourly basis to physician unit to reach the
desired scope of activities plan. A nurse is provided who teach the light exercise
related to deep breathing, lease of lung expansion and expectations of any
sputum. The pressure will be relieved with standing position on chair by
moving from chair to bed and vice versa (Petherick, Pickett and Cullum, 2015).
It facilitates to make patient feel happy and accordingly hypertension will be
released in relatively short time span. Light attire is preferred for Robert for
night as well as day with appropriate atmosphere of room as in leg ulcers the
itchy clothes may increases the pain of the patients. For this purpose, windows
are left open along with anti-pyrexia medication to provide peaceful sleep over
night to relieve their pain. Apart from this, plan is implemented for mouth dry in
term of use of 24% via nasal inhalers. Diet chart is prepared and accordingly
liquids is offered in the small interval which includes soups, milk based drinks
and smoothies.

Evaluation
The evaluation of care plan is very important as it provides support to
care workers that support their existing conditions in order to improve. It assists
researcher to understand that how was the quality of services provided to
patients and was it effective to bring improvement or not. It is also effective to
understand that whether care plan should be changed or not.
On the evaluation procedure and during interview process it was found
that condition of Robert was improved. Here, NEWS was inspected in 1-hour
basis and was found that score is less and equal or 4. Score for water low was
greater or less than 8 in the interval of 2 hours. Apart from this, fluid balance
was daily weight and BMI will be ascertained once in a week as normal patients
as it has role in this disease for checking hourly basis. Further, peripheral
oedema was assessed on the basis pitting assessment on daily basis (Lazarus
and et. al., 2016). The mandatory requirements were related to dietary intake at
mealtimes and 48 hours’ time interval was kept where score must be greater or
equal to 3. Apart from this, mobility is assessed on daily basis and moving as
well as handling activities are observed. 4 hourly signs of infection is assessed.
Moreover, urinary catheter will serve as the basis for evaluation where pressure
is relieved after each pressure which facilitate the patient to check their relieved
pain on specific time interval. In addition to this, it was found that patient is
getting necessary treatment as per the disease and accordingly releasing the pain
by and by. Apart from this, level of pain was reduced to zero by using
analgesics and good diet. Therefore, care plan was effective and it led
improvement to patient's mobility and ulceration.

Conclusion
The report concludes that nursing practices should be implemented in
care home with extensive care. Nursing theories and concepts as well as beliefs
must be understood among all nursing staff which will have direct impact on
service users. It can also be said that nursing process is the standardized method
for rendering care. Furthermore, nursing diagnosis is applied for effective
assessment of patients so that appropriate care plan can be prepared by nursing
practices. Apart from this, Venous Leg Ulcer tends to affect quality of life of
one person whereby service providers focus upon certain aspects and
accordingly treatment is provided. In addition to this, Roper-Logan-Tierney
activities of living model is very helpful in extracting important information of
clients or service users. The good impacts of the carper’s model will also help
the doctors in assessing the good or bad results generated from this model
which has several elements such as environment, health and peoples as this play
a significant role in the life of all the individuals in providing their valuable
services to all the patients suffering from venous leg ulcers.

Recommendation
It has been found that Roper-Logan-Tierney should be implemented by
nursing staff to ensure effective care of patient. This can be used as checklist so
that patients can be observed in an effectual manner. However, framework for
individualized assessment and holistic should be used by taking base of RLT
model. This facilitates to understand the current mental state as well as health
condition of patients. However, certain national guidelines should be provided
for Venous Leg ulcer so that nursing staff can work accordingly (Viv as, Lev-
Tov and Kirsner, 2016). On the other hand, care workers should be provided
time to time training so they will effectively take part in improving the service
quality. The actual ratings of urinary catheter in form of using PCA ratings will
be used to strengthen the treatments.

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APPENDIX 1
APPENDIX 2

APPENDIX 3