I. INTRODUCTION:
In any human endeavor, in medicine as a cardinal example, when ever facts are sparse, strongly held theories proliferate. Because the pros and cons for the use of medicine in psychiatry are not absolutely clear or agreed upon, strong arguments have risen on all sides. Radical biologists insist that all psychiatric illness result from abnormalities in the brain. Drugs are almost seen as the answer and the adverse effects as simply inconvenient. To these practitioners “talking” therapies of whatever variety are simply a waste of time.
Diametrically opposed to the radical biologists are the dogmatic psychologists who insist that psychiatric problems are not medical problems but rather the products of unconscious conflict, bad life experiences, incorrect thinking, or adverse social circumstances. These theorists are fond of claiming that medical treatments “cover up” psychiatric symptoms, whereas psychological treatments-be they psychoanalysis, behavioral modification, cognitive restructuring, and so on-get the true “root” of the problem (Gorman, 1990).
My objectives however as a practicing mental health nurse and as a counseling psychologist is not to create a division in the clinical practice. Rather, to create an understanding and a better picture if both practice is utilized in the welfare of our clients in the mental health profession. In this regard I opted to utilize and employ the Biopsychosocial Model (BPM) of psychiatry in the presentation of my case analysis. BPM was popularized by psychiatrist George L. Engelis. This is a general model or approach that posits that biological, psychological (which entails thoughts, emotions, and behaviors), and social factors, all play a significant role in human functioning in the context of disease or illness. Indeed, health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms (Santock, 2007).
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The biological component of the biopsychosocial model seeks to understand how the cause of the illness stems from the functioning of the individual’s body. The psychological component of the model looks for potential psychological causes for a health problem such as lack of self-control, emotional turmoil, and negative thinking. The social part of the model investigates how different social factors such as socioeconomic status, culture, poverty, technology, and religion can influence health. The biopsychosocial model implies that treatment of disease processes requires that the health care team address biological, psychological and social influences upon a patient’s functioning. In a philosophical sense, the biopsychosocial model states that the workings of the body can affect the mind, and the workings of the mind can affect the body. This means both a direct interaction between mind and body as well as indirect effects through intermediate factors (Halligan, P. and Alyward M, 2006).
This is the case of Remi P. Gandanghari (not real name); other data are presented in chapter II. I choose her as my client for process recording and case report because I was the nurse on duty when she was admitted. From there on she sought for voluntary counseling after her condition was stable. She was controlled by her medication and she is currently in remission from her illness. She is now an outpatient client, who religiously comes for follow-up checkups in our institution. The following methods of information gathering techniques were utilized to obtain information regarding my client: 1. Patient’s Chart The information contained in the medical record allows health care providers to determine the patient’s medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient’s care (Udan, 2004).
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2. Behavioral observations are descriptions of the patients coping, adjustments, thoughts and actions, feelings and perceptions directly observed by the staff. The non-verbal way the patient is communicating (Udan, 2004).
3. Nurse-Patient Interaction is a professional relationship in which trust is the basic element (Udan, 2004).
If trust is developed the client can easily open information regarding her condition, thoughts, and feelings. 4. Anecdotal reports are descriptions of a client’s unusual or unexpected behavior in a given situation or event. Such reports are subjective and descriptive in nature and recorded in narrative form. (Villar. 2009).
5. Interview of significant others with parents, siblings, and other significant others provide useful information which when put together, can form a well rounded picture of the client especially if collected over time and examined side by side(Villar,2009).
6. Intake interviews are initial interviews where the counselor collects information on the client’s concerns, current status, and certain personal traits (Villar, 2009).
7. Summary of counseling sessions These data can also help succeeding counselors and other mental health workers over time. Session summaries give the gist of each session with the client (Villar, 2009).
Under the patients’ bill of rights and Mental Health Systems Act the patient has the right to confidentiality of records. Information regarding the clients profile and primary health care providers are substituted under their pen name to preserve Anonymity (Keltner, 1999).
Some information’s are omitted and only relevant information for the study was used. Client’s consent for case report was obtained verbally after all ethical considerations were explained. Significant others and primary caregiver were also informed of the researchers intentions for case study, verbal consent was also obtained. II. GENERAL DATA
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Reliability of Information- 98% – from Clinical case record
Informant- Immediate family member (Sister)
Clinical Interview – Nurses admission notes and Psychiatrist notes
DEMOGRAPHIC DATA:
Full Name: Remi P. Gandanghari (Not real name)
Age: 48 y/o
Sex: Female
Birth Date: May 30, 1964
Birth Place: Baguio City
Address: # XX, Puguis, La Trinidad Benguet
Civil Status: Not-legally Separated
Religion: Roman Catholic
Nationality: Filipino
Educational Level: College Graduate – Commerce and Finance Occupation: Vendor: Vegetables
Date Admitted: 03 April 2013
Time Admitted: 6:30pm
Admitting Physician: Dr. WST
Attending Physician: Dr. WST
CLINICAL CASE RECORD
Past of Illness:
Patient was admitted before in the mental health institution (RRCC) in 1999
with the diagnosis of Bipolar with Psychosis and was treated and discharged thereafter. Patient had regularly taken home medications and was seen on consistent basis for her follow-up check-up which lasted for only 3 months. Patient as admitted from March 25, 1999 to June 7, 1999. She was discharged, improved with Chlorpromazine 100mg Bid, Paroxetine 2omg 1 tab. O.D. and Biperiden HCI 20mg ½ tab BID. She had 4 follow-ups with undersigned, last of which was April 5, 1999 then lost her follow-up thereafter. She had on and off symptoms but was not tolerated as she was able to help out at the trading post. She was often noted to be at the trading post with her condition but she was tolerated by other people who knew that she was ill. History of Present illness:
Last 1st week of September 2012, client was not attending work, client was exhibiting bizarre behavior like shouting at people passerby, splashes water to people pass by at her work place, neglecting house chores and personal hygiene, neglecting work and take things that does not belong to her, patient is also observed to be hoarding things that are unusable, this persisted up to the succeeding months.
Second week of November client was seen at the PNP office with her cousin due to theft at department store for stealing pants, t- shirts and bags; client was imprisoned at BCJM for theft. Patient was brought into RRCC for admission and further care and management.
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At present, patient continues to manifest inappropriate smiles, exhibit auditory hallucinations and delusions. She recalled taking a shirt and a pair of pants at SM but believed that it was given to her. She also believed that the people at the mall were communicating with her through hand signals or gestures. In the ward, she verbalized suicidal intent in front of hospital personnel and nursing students.
Patient is presently being managed as a case of Schizoaffective Disorder, characterized by disturbances in mood associated with symptoms of psychosis such as auditory hallucinations, delusions, unusual gestures and behavior, impaired insight and judgment, suicidal thoughts and impaired somatic functions. Medications:
The following medications used by Ms. Gandanghari are explained according how they were used in relation to her illness, and prescribed by Dr. WST. Drug properties, classifications and indications were cited from (Malseed, 2007).
1. Olanzapine (Zyprexia) 10mg. Olanzapine is belonging to the 2nd generation of antipsychotics. However in the case of Remi Gandanghari the medication was used not to treat psychoses rather a short term- treatment for manic episode associated with bipolar I disorder. After her in-patient stay, this drug had been her maintenance treatment and Valpros.
2. Valproic Acid (Valpros) 500mg tab. Is a mood stabilizer, primarily used to treat bipolar disorder – manic phase, this was adjunct therapy with Zyprexia for Ms. Gandanghari for her maintenance.
3. Clonazepam (Rivotril) 200 mg ½ tab. Is a benzodiazepam commonly prescribes for epilepsy and other seizure disorders. On minimal doses it is commonly used for as a sedative. In the case of Remi Gangahari Rivotril was used as a prn for sleeplessness. In the acute episodes of her illness, somatic complaints were rampant, in the first few days of her hospitalization patient complained of irritability and restless leg syndrome. Rivotril was shifted as an h.s. medication to combat restless leg syndrome. 4. Sertraline (Zoloft) 100 mg tab. Is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class, it was used as the drug of choice for Ms. Remi during her major depressive episodes.
5. Riperidone (Risdin) 2mg tab. This was used in the case of Ms. Remi during her mixed phase of bipolar disorder. This is an atypical antipsychotic, however this drug is also useful in treating – resistant depression, Ms. Remi did however developed Akitisia in the long term therapy of this drug that’s why it was discontinued to her and replaced with Olanzapine.
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6. Biperiden (Akineton) 20mg. is an antiparkinson agent – anticholinergic type. This was ordered as an adjunct treatment with antipsychotics of Ms. Gandanghari when Akatishia, muscle rigidity and tremors were evident with the use of Ms. Gandanghari with her antipsychotics.
Latest Diagnostics:
1. Psychological Report: Philippine Mental Health Association, Inc. Baguio-Benguet Chapter Date Tested: 06, April 2012
Date of Report: 09, April 2012
Tests Administered:
Bender Gestalt test
Draw-A-Person Test
Gorden Personal Profile/Inventory
Incomplete Sentence Blank
Raven Progressive Matrices
Association Adjustment Inventory
BEHAVIORAL OBSEVATION:
Client came for testing wearing a black t-shirt, jogging pants and a pair of ankle length boots. She looked unkempt with her uncombed hair; Mrs. Gandanghari also appeared to have some time spent crying. Prior to the testing proper, she approached the examiner and expressed her desire to leave Roseville. Client denied that she was sick and insisted that her sister made a mistake in bringing her to the center. She even cried that she missed her 10months old son whom she was breast feeding. After sometime, Mrs. Gandanghari calmed down and tried to negotiate with the examiner saying that she would take the test if the management will release her. Client cooperated with the testing when convinced by the examiner. However, Mrs. Gandanghari stopped several times and kept reiterating her wish.
She worked fast and was able to accomplish the psychological test battery in about 2 ½ hours. Her bender figures were noted to be enlarged while her human figures drawings were unproportional. Client’s strokes were also light and sketchy. TEST RESULTS AND INTERPRETATION:
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Intellectual Evaluation:
Based on the 60 item abstract reasoning test given, client is classified to be intellectual functioning within the below average with her score of 33 and its equivalent percentile rank of 8. Mrs. Gandanghari’s IQ is estimated of 79. She may therefore find it difficult to deal with figure related tasks. Likewise she is below average in learning new concepts in recalling acquired information. Client has adequate verbal skills. Emotional Evaluation:
Self-rating test show that she appears to display a fair sense of responsibility. Mrs. Gandanghari is likely to be unable to stick to a task which she considers it uninteresting .Client also sense to have a low energy level hence, her penchants for maintaining a slow pace while at work.
She rated herself as emotionally stable, free from anxieties and nervous tension. However, her projective test result suggested otherwise. Mrs. Gandanghari seems to be intensely anxious and insecure. However, she may try to deny her limitations by resorting to compensatory defenses. Client’s coping strategies include her tendency to be vain and overly concern with outward or physical appearance. She may also be hostile and aggressive to the point of acting out her behavior. Mrs. Gandanghari can direct her anxieties towards others either verbally or physically.
Socially, she may consider herself as inadequate hence, she is likely to be withdrawn and evasive, because of her tending to be irritable and her highly critical attitude, she may find it t difficult to maintain deeper and more meaningful interpersonal liaisons.
Mrs. Gandanghari seems to be impulsive, preferring to make decision on the spun of the moment. She is likewise poor in terms of anticipatory planning ability. Client can also be moody that she may vacillate between being depressive and being reactive or emotional. She may try to avoid unpleasant and frustrating situations. Maternal dependency and infantile needs are also hinted in her test protocols.
In sentence completion test client disclosed to ‘’her family could not understand her’’. She also expressed her problem with her husband whom she described as “irresponsible”. Mrs. Gandanghari thinks that her husband and in-laws are laughing at her. She also feels that she is “not accepted in the family”. At present, she seems to be confused and still unable to think logically. SUMMARY AND RECOMMENDATIONS:
At the time of testing, client is estimated to be intellectually functioning in the below average range with an IQ at 79.
Emotionally, she seems to be fairly responsible with low energy level. Client is also likely to be anxious with felt lack of adequacy but she may cover up her feelings by resorting to compensatory defenses. Mrs. Gandanghari may therefore be vain, aggressive and hostile to the point of acting out her behavior. She can be moody, impulsive and dependent. Likewise, client appears to be evasive and withdrawn. Psychotic trends also yielded in her test results.
Her problem with her family and husband had been clearly manifested in her completion test responses.
With the foregoing findings it is highly recommended that client continues undergoing psychotherapy/ counseling sessions to help her process her feelings considering that her mind is still clouded by her problems. She also needs to learn or to acquire effective ways of coping with stressful situations.
Recreational/ relaxing activities may prove beneficial in helping, Mrs. Gandanghari find means refresh herself and her mind from worries.
Family therapy seems warranted for the client and her husband as well as her family (parents, brothers, and sisters).
This is to thresh out negative feelings between members of the family in relation to the client’s predicament. It is also one way of showing Mrs. Gandanghari that she is supported by her loved ones.
2. Clinical Interview
NURSES ADMISSION NOTES:
Into RRCC this 48 y/o female referred by the police department due to pressing charges of theft at SM department store. Patient was accompanied by sister for consultation. The patient had previous history of confinement in this institution in 1999 with a diagnosis of Bipolar Disorder with Psychosis. Prior to consultation patient was in the correctional, with crying spells and talking to herself.
Last week of September client was not attending work at the trading post as a vegetable vendor, she exhibited bizarre behaviors such as not going home, neglecting hygiene and hoarding things that she picks up along the way.
Patient was poorly groomed, unresponsive to interrogations. Disoriented to time and place but oriented to persons. Cooperative when vital signs were taken. Significance other claims that she has good appetite but poor sleeping patterns. Clad in yellow shirt, blue jeans and black rubber shoes. She was seen and examined by Dr. WST for further care and management. PSYCHIATRIST NOTES:
Health History: the patient’s health during childhood was considered normal except for some kind of psychological disturbances such as fears and concern about cleanliness. In her adolescent stage, so far, no problems have been reported about physical problems and she has never experienced any surgical operations. At present the patient is being treated for type 2 hypertension and has been taking maintenance of Amlodipine 50 mg OD. Family History: the patient has six other siblings; she is the fourth child. She has 2 brothers and 3 sisters. The first child is a government employee working in a Municipal office as a maintenance man, married and separated from their parents, currently residing at the Sagada Mt. Province.
Her sister, the second child is a Medical student in her internship, single and still resides with their parents. The 3rd child; her sister is married, unemployed and a plain housewife, living together with her husband in Abra. The 5th child is unemployed, married, they are dependent on his wife’s salary as a domestic helper in Hong Kong, and they are residing in La Union. The last child is an elementary teacher, single, working at Bontoc Mt. Province. Her parents are living together, both retired teachers and are currently residing at La Trinidad. Educational History: the patient stopped schooling at age 18 due to financial problems encountered by the family and resumed her schooling at age 21. She was able to finish her course Commerce and Finance at age 24 and graduated with colors. She started her master’s degree in business administration but was unable to finish her graduate studies. Work history: The patient is presently unemployed but she has experienced working once in a bank as a teller but after 2years she stopped.
During the course of her remission she was able to keep a job as a vegetable vendor in the trading post in La Trinidad. Patient’s interpersonal relationship: According to the patient, she makes friends easily and has the ability to keep them. But according to her relatives, they have observed that the patient has poor interpersonal relationship; she is not active in making friends and dealing with them. She usually spends her time inside her room. Psychosexual history: The patient gained her first knowledge about sex when she was in high school and it was revealed also that at the same stage, she was able to become aware of her own sexual impulses. She does not have any anxieties or guilt feelings arising out of sex or masturbation (These are according to the patient.) However she just said “none” on the question asked, “Is your present sex life satisfactory?”
It was also reported that the patient did not have a boyfriend in her high school and college life. Marital history: the patient got married at age 34. Her husband was a 38 y/o man, laborer. She stated that she met her husband from one of their family trips to the province. Her parents favored her decision to get married when she introduced him to them. Special personal hobbies and interest: her hobby is singing and playing the guitar most of her free time is occupied playing the guitar. 3. Lab Works:
1. Clinical Chemistry: FBS–Fasting blood sugar is a routine procedure for most patients in drug therapy for antidepressants to obtain a baseline (Evan and Reiss, 2007).
Since antidepressants such as SSRI increases the blood sugar, thus Mrs. Gandanghari is using Sertraline. The baseline blood sugar could also be useful in determining irregularities in the metabolic process. Example major shifts from antidepressants types such as SSRI to MAOI’s. In contrast to SSRI MAOI’s decreases the blood sugar level, therefore prior to any use of antidepressant FBS must be obtained first.
2. Urinalysis: most of the time prior to psychopharmacotherapy U/A is ordered not as a diagnostic tool rather, same through with FBS, it serves as a baseline data for assessment. When in Drug therapy, U/A should be done monthly to determine the kidney function test since some mood stabilizers are nephrotoxics.
3. Hematology: CBC– Like the other test above Complete Blood Count serves also as a baseline data before pursuing Psychopharmacologic therapy. In the course however of screening, if irregularities such as infection – indicated by leukocytosis, and/or drug toxicity – indicated by thrombocytopenia may be present, psychopharmacologic therapy may be withheld (Evan and Reiss, 2007).
4. Liver function test: AST and ALT – are biomarkers of liver injury. It is a screening also for functionality of the liver, since most psychiatric medications are hepatotoxic it is a routinely procedure to assess fist the functionality of the liver before and during drug therapy.
III. PSYCHOSOCIAL PROBLEM LIST:
Problem identification was done in a tabular manner to facilitate easier understanding of the problem and to easily inject the interventions suitable for the patient. Maslow’s hierarchy of need was utilized in problem identification since; in the case of the patient a lot of these needs were neglected, deferred and altered. Legend of the scores given:
Verbalization:
0 – not verbalized
1 – Verbalized when asked only
2 – Verbalized even when not asked
3 – Verbalized numerous times
ABC’s of Psychiatry:
1 – (A) – Affective
2 – (B) – Behavioral
3 – (C) – Cognitive and thought process
Kind of Problem:
2 – Actual
1 – Potential
Maslow’s Hierarchy of Needs:
1 – Self Actualization
2 – Self-esteem
3 – Love and Belongingness
4 – Safety and Security
5 – Physiological
V. INTERVENTIONS:
Biological problems:
The lists of biological problems of Remi Gandanghari were identified. Some nursing interventions are dependent to the medical interventions ordered by the psychiatrist. In the course of her psychopharmacologic therapy standard nursing interventions must be done with strict precautions. In the course of this therapy nurses must be able to identify adverse effects and side effects of the medications and report to the primary caregiver if these effects are present (Evans, 1990).
A patient on mood stabilizers such as Valproic Acid (Valpross) may exhibit somatizations, the nurse must be able to identify if symptoms are real in such cases it is still a need to refer complains to the primary care giver. Time of administration, dosage and blood tests to check serum level or toxicity must well be done with caution and strict compliance.
The independent nursing care should also be performed as the need arises. In the case of Remi when she is in her depressive phase, neglect for hygiene and appetite are the common problems encountered. If this occurs the biologic need must be filled by the nurse. Hygiene and self-care activities are encouraged and as much as possible “independently”. Staying with the patient is also a must. One time when her meals was served she remained motionless; shifting to a catatonic state, as the nurse on duty I took the initiative to feed her by assisting her hands with the spoon and fork, this persisted for almost two days during meal time however significant changes were seen when she took the initiative to feed herself. Impairment in the role performance is common among depressive patients. The loss of initiative and motivation are only a few to this factor.
When I interviewed her for not joining occupational therapy and reasons for confinement to her room, she stated that she is feeling irritable, restlessness and tremors are seen and she keeps pacing along the hallway of her room. It was later discovered when referred that she is having Extrapyramidal Side Effects (EPS) particularly Akathisia from Risperidone; Biperidin was prescribed to counteract this effects. When the EPS was controlled she was able to join the occupational therapy and activities in the ward. Motivation and initiatives’ to perform certain tasks were observed. She was able to have surpassed her depressive state, she was able to verbalize her concerns and she was able to detect symptoms of EPS and report it to the staff as it occurs. Psychological Problems:
A lot of her problems identified to be deeply rooted in her psychological constructs. A person weak psychological construct usually are easily predisposed to mental illness. Remi has undergone a lot of stressors which has inhibited her psychological growth and wellbeing. Self-harm is only one of the ways she sees as the route to escape these problems. In one of the Remotivational activities conducted by affiliating student nurses she verbally declared her wish to die, when I processed this incident she began crying and told me that she has no use in this world. She states that “A person is useless if she has no grasps of reality”. As nurses the primary intervention is to institute S.H.E (Suicide, Homicide, and Escape) precautions. Suicide actions may have varying reasons from each individual: an escape, a form of solution to the existing problem, but for Remi she internalized her hatred to the events that have happened in her life, she viewed herself as the root cause of all this events – from their marital break-up to problems with her family, and her inferiorities among her siblings.
Homicidal precautions were instituted since suicidal patients may potentially divert their suicide drives to others. Escape precautions are necessary in the case of Remi because most suicidal patients may relapse into this action until it becomes successful, she may look at the possibility of escaping and performing the suicide act with no one to prevent her. Spiritual distress, disturbance of the thought process, and impairment of her personal identity may be correlated with situational crises. The best intervention is to assess her spiritual beliefs her faith and her spiritual practices.
In one of the Nurse-Patient Interaction Mrs. Remi confessed her loss of faith to a supreme being, she once shared that no matter how much she prayed God isn’t answering her prayers, God has forgotten me as she stated with remorse. Assessment of the thought content, manifestation and cognitive distortions was done and re-orient patient back to patient as necessary. Loss of Personal identity is a process that happens not only to a single individual, rather a universal concept that an individual journey to complete. Therefore this must be carefully explained, reality therapy or existential philosophy was implemented in our counseling sessions. Social Problems:
Social interaction disturbance was noted in Remi’s case when she refuses to actively participate in the activities in the ward. A week after admission she isolated herself and often remained confined in her bed. Stable patients were however friendly to her. In one of our exercises program we encourage her to lead the morning exercise, she hesitated at first but when we reinforced a behavior that she would get ground privileges and TV privilege, she took the challenge provided that she will be accompanied by another patient. Remi and this patient became friends and they lead the morning exercises together every day as partners. This example is just one of the interventions a nurse must develop, this skill is as important as the survival for most of the patients. I have seen a lot of changes then thereafter she met XXXXXXXX.
Mental illness does not only affect the person suffering from it; it is also a problem among the family members. Disturbance in the family process was identified as a problem, not only in the financial means but also the coping and adjustments of the family members in the case of Remi. During one of the visits of her sister the interaction between the sister and the nurse was initiated it was later found out that the family members are running out of financial resources for her medical bills and institutionalization. It was also noted that the case they are pursuing against the management of SM for her case theft, takes a big stress among the family members.
The intervention that was conducted was the behavioral observations of her progress was shared, when I shared to the sister who is a medical student, the progress of Ms. Remi on her compliance to the treatment regimens and her initiative and motivation to be treated the sister burst into tears of joy and was elated to share the news to the other members of their family especially to Remi’s daughter. The sister thanked us and from here on the duration of her visitation was done by the family members twice a week. V. SUMMARY, CONCLUSIONS AND INSIGHTS
Bi-polar and Mood disorders are just one of the realms of psychiatry. People with this illness are often misunderstood and often times being criticized for their inappropriate behavior. Sadly, some even blame this disorder to themselves. Worst others are often labeled with this stigma throughout their lives corrupting their functions, relationships and their selves. People with this disability and all types of mental illness wake up for an unending battle – the battle against self! Ms. Remi is just one among this people gearing up for her battle. She was institutionalized because of brief psychotic breakdown and exacerbation of her illness. She was discharged after 2 months in our institution, after which she was summoned in court for her case of theft, according to her in one of her out-patient check-up the case was dismissed after the court’s decision of mental incompetence.
She has fully accepted her illness, she redirected her goals and she focused on these goals. She maintained her take home medications, religiously comes for follow-up. Today she is facing another battle, to continue living! The Biopsychosocial model of psychiatry was utilized in the case conceptualization of Ms. Remi. The problems were identified, interventions were explained and the nursing diagnoses were presented. Throughout our practice as nurses encounter patients that would mold us, inspire us and define what really our profession is. Sometimes the reward itself in nursing is to see the improvements of our patients, by the smallest details of our interventions we bring back the lives of the patients that were stolen by their disease. This is my experience in the case of Ms. Remi and I hope that in my practice as a psychiatric and mental health nurse, as a counseling psychologist this experience would be applicable to all my patients. In the end, the philosophical underpinnings of Carl Rogers’s humanistic psychology “never give up on the patient” is best applicable in our practice as nurses.
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