The nursing care plan for clients with sepsis involves eliminating infection, maintaining adequate tissue perfusion or circulatory volume, preventing complications, and providing information about disease process, prognosis, and treatment needs. Nursing Diagnosis: Risk for Bleeding related to invasive surgical procedure. Nursing Care Plan Psych Psychiatric And Mental Health. 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Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Continue with Recommended Cookies, Thrombocytopenia NCLEX Review and Nursing Care Plans. Administer blood or platelet transfusion as prescribed. It gives a quick glimpse on the intensity of care the patient needs. Anna Curran. Alternate periods of physical activity with rest and sleep. These are the nursing interventions for pneumonia nursing care plans with Risk for Infection nursing diagnosis: Nursing Interventions Rationale Assessment During this period of time, Monitor vital signs closely, potentially fatal complications especially during initiation of (hypotension, shock) may therapy. Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related glomerular malfunction to secondary to chronic kidney disease as evidenced by increase in lab results (BUN, creatinine, uric acid, eGFR levels), oliguria or anuria, peripheral edema, hypertension, muscle twitching and cramping, fatigue, and weakness. Tell the patient to report signs and symptoms of infection and teach her about any prescribed antibiotics. Nursing goals for a child with Kawasaki disease may include increased understanding of the parents and child about the disease condition, medical treatment and planned follow-up care, relief of pain, improved physical mobility, adequate coping, and absence of complications. Buy on Amazon, Silvestri, L. A. Measurement of the patients fluid intake and output is one of the effective ways to evaluate kidney function. Any condition that causes enlargement of the spleen can cause it to trap more platelets than usual, hence affecting the number of platelets in the blood circulation. Health & Medicine Introduction, definition, types, etiology, pathophysiology, clinical manifestations, diagnostic tests, medical management, surgical mangement, nursing management with nursing diagnoses, health education of intestinal obstruction. Cardiac Care Plans, Nursing Care Plans, Pediatric Nursing 4 Acute Rheumatic Fever Nursing Care Plans Join NursingCenter on Social Media to find out the latest news and special offers. Peripheral tissue perfusion can be assessed in several ways. Saunders comprehensive review for the NCLEX-RN examination. 00 Comments Please sign inor registerto post comments. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Before the operation, obtain blood samples (Labs) to check platelet counts as well as coagulation levels (INR, PT, and PTT). Fracture Nursing Care Plan By Maye Serrano R.N. Patient takes measures to prevent bleeding and recognizes signs of bleeding that need to be reported immediately to a health care professional. Desired Outcome: The patient will develop an understanding of the importance of protecting the involved extremity from further injury. Nursing care plans: Diagnoses, interventions, & outcomes. If no improvement, pack the nose with vasoconstrictor-soaked gauze and a heavy coat of petroleum jelly for 10 minutes. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. The Nursing Care Plan for Hypospadias with Assessment and Diagnosis is a kind of Information Nursing Care Plan Examples are much sought after on the internet and has linkages with various information Nursing Care Plan other Examples. To enable to patient to have specialized advice on renal diet while incorporating his/her food preferences. Here are 6 pleural effusion nursing care plans (NCP). This is mostly recommended in cases of splenomegaly if it is the cause of thrombocytopenia. Some error has occurred while processing your request. This slender, fast-moving snake lives in the treetops, where its vivid green-a Ineffective Tissue Perfusion Nursing Care Plans Diagnosis and Interventions Ineffective Tissue Perfusion NCLEX Review and Nursing Care Plans The cells are the building blocks of the human body. Cartwright SJ, Morris JJ, Pinder D. Managing nosebleeds. Hair growth often signifies good perfusion while purplish to cyanotic skin is associated with reduced or absent tissue perfusion. Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related to low levels of cellular components required for oxygen delivery secondary to chronic anemia as evidenced by hemoglobin level of 6.9 g/dL. Hemolytic uremic syndrome. To reduce the risk of trauma to the oral mucosa and gums, which may lead to a bleeding episode. Some medications can reduce platelet levels. Provide low-microbial diet. Bacterial infection. 2008. http://emedicine.medscape.com/article/994459-overview. It serves as a guide in anticipating the patient's healthcare needs. Mental Health Psychiatric Nursing Review Questions with. How do you write a nursing care plan (NCP)? Buy on Amazon. Reduced activity and stress levels can reduce the bodys oxygen demand and prevent fatigue and poor tissue perfusion. Here are four (4) nursing care plans (NCP) for Hypovolemic Shock: Here are some of the most important NCPs for diabetes: 1. to maintaining your privacy and will not share your personal information without These conditions include: Immune thrombocytopenia. It can range from mild to severe depending on how low the platelet count is. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. It is an autoimmune condition where the body attacks its own platelets. Reduction of dietary protein means reduction of waste products, giving the kidneys rest and preventing further deterioration of renal perfusion and function. Obtain specimens for blood work, including complete blood cell count and coagulation profile, as prescribed. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. may email you for journal alerts and information, but is committed This helps prevent nausea and vomiting and lets you estimate the amount of bleeding. Nursing management Monitor for patient vital signs assists in the control of bleeding. Orthostasis (a drip of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP when changing from supine to sitting position) indicates reduced circulating fluids. Goals can be short term or long term. When this mechanism fails due to several causes, the NANDA nursing diagnosis Ineffective Tissue Perfusion may be used. Nursing Diagnosis: Hyperthermia related to the disease process of osteomyelitis as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse. After bleeding is controlled, reassess the patient and provide oral care. Ineffective airway clearance. Here are three (3) nursing care plans (NCP) and nursing diagnosis for glaucoma: 1. Practice deep breathing (with incentive spirometer) every 4 hours while awake. Please try again soon. Reassure the patient. Buy on Amazon, Silvestri, L. A. Anterior bleeding is usually managed by digital pressure, gentle chemical cauterization, or nasal packing. Labs are only necessary in cases that do not respond to treatment. Chapter 25 Newborn Nutrition and Feeding My Nursing Test. Risk for Bleeding Nursing Care Plan 2 Peptic Ulcer Disease 3 Suicide Behaviors Nursing Care Plans ? Teach the patient how to sit on a commode to avoid straining (renal damage). In the wild, they live about six years, Jillson said. If bleeding is significant, establish vascular access, place the patient on a cardiac monitor, and begin fluid resuscitation with a crystalloid solution, as prescribed. She received her RN license in 1997. Includes our easy-to-follow guide on how to create nursing care plans from scratch. Nonmaleficence is the duty to do no harm. It commonly varies in size, severity, and treatment needed. As an Amazon Associate I earn from qualifying purchases. The patient should have a high fiber diet to help prevent constipation. Desired outcomes should be realistic for the clients resources, capabilities, limitations, and on the designated time span of care. Reassure the patient. Monitor blood glucose levels, especially if the patient is diabetic. educate client's about every kind of procedure. I hope to learn more and improve my skills towards nursing. Collect urine and stool samples for occult blood testing. Quickly assess the ABCs (airway, breathing, and circulation) and support them as indicated. Inherent coagulopathies 7. Tube feeding Biophysical: 1. To increase the platelet count and hemoglobin level and treat thrombocytopenia, anemia and hypovolemia related to bleeding. HOME NURSING CARE PLANS 9 ASTHMA NURSING CARE PLANS 9 Asthma Nursing Care Plans UPDATED ON JANUARY 3, 2023 BY PAUL MARTIN, BSN, R. ADVERTISEMENTS Menu In this guide are nine (9) NANDA nursing diagnosis for asthma nursing care plans including their nursing assessment and interventions. Avoid suppositories, enemas, rectal temperatures. homes near me november 2014, acute respiratory distress syndrome ards nurseslabs, ubenwa cry based diagnosis of birth asphyxia, ncp for hypoglycemia . 2008;16:212-214. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. Here we'll formulate a scenario-based sample AFib nursing care plan.It will include three sample nursing care plans with NANDA nursing diagnosis, nursing assessment, expected outcome, nursing interventions, and rationales.. What is AFib? The Nursing Care Plan for Epistaxis is a kind of Information Nursing Care Plan Examples are much sought after on the internet and has linkages with various information Nursing Care Plan other Examples. Refer the patient to physiotherapy / occupational therapy team as required. Provide an emesis basin and tissues. This is to assure theavailability of blood when needed. Buy; In Brief. In cases where the platelet levels fall below 10,000 platelets per microliter, severe bleeding in the brain may occur. The damage to the small blood vessels causes the formation of blood clots causing the destruction of red blood cells and platelets. Tell her to spit blood into the basin if necessary. Maintain seizure precautions. Nanda Nursing Diagnosis: Nursing Diagnosis for Epistaxis-is the health information you're looking for. Prepare the patient for splenectomy as indicated. They are produced in the bone marrow together with the red and white blood cells. Administer humidified oxygen by facemask to a patient with posterior packing. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. Client health assessment, medical results, and diagnostic reports. Course Catalog Edmentum. To gradually increase the patients tolerance to physical activity. Data is temporarily unavailable. Advise patient to use a soft-bristled toothbrush as well as a non-abrasive toothpaste. Blood product transfusions replace blood clotting factors; RBCs increase oxygen-carrying capacity; FFP replaces clotting factors and inhibitors; platelets and cryoprecipitate provide proteins for coagulations. Please try after some time. Nursing interventions are directed at prevention. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Tell her to apply water-soluble ointment to her lips and nostrils while packing is in place and to use a cool-mist room humidifier. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient. Encourage the patient to follow a low cholesterol, high caloric diet. assist with turning,coughing,and deep breathing. Burns Nursing Care and Medical Management, Myocardial Infarction (MI) Nursing Care and Medical Management, Meningitis Nursing Care and Medical Management, Hypertension Nursing Management & Desired Outcomes, Chronic Obstructive Pulmonary Disease (COPD) Nursing Management, Nasal trauma (nose picking, foreign bodies, forceful nose blowing), Drying of the nasal mucosa from low humidity, Deviation of the nasal septum or septal perforation, Bleeding polyp of the septum or lateral nasal wall (inverted papilloma), Tumors of the nasopharynx especially Nasopharyngeal, Medication(ex.aspirin,anticoagulants, anti-inflammatory drugs), CBC with platelet count, PT/PTT and bleeding time, CT scan or Xray of the sinuses and nasal area to search for neoplasm of the nasopharynx and sinuses. Administer anti-fibrinolytics as a second-line treatment. ; Decreased cardiac output may be related to inotropic changes, alterations in rate and rhythm possibly Drugs may also be the reason why a patients bone marrow function is suppressed which increases the patients risk for bleeding. A discussion with the patient regarding risk factors may prevent further injury and promote understanding of the importance of lifestyle modifications to prevent this from happening again. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. If the blood loss is too much and immediate correction is warranted, whole blood transfusion is administered. Reassure the patient. A detailed nursing assessment guide identifies the individual's risk for injury and assists with the clinical decision by indicating which interventions should be included in the care plan. Endocrine and Metabolic Care Plans, Nursing Care Plans Free; Metrics In Brief. St. Louis, MO: Elsevier. Don't leave the patient unattended during -epistaxis. Please try again soon. 2204 Intervention with a Suicidal Client Flashcards Quizlet. Most episodes of bleeding from the nose resolve before the patient arrives at the medical care facility, but persistent or recurrent bleeding requires immediate intervention. Resuscitation with IV fluids or possibly blood transfusion may be necessary for severe blood loss to prevent hypovolemic shock. Thyroid Cancer 3 Nursing Diagnosis and Interventions. Obtain blood samples to monitor coagulation essays for factors VIII and IX. Nursing diagnoses handbook: An evidence-based guide to planning care. MCERLANE, KIMBERLY RN, CNS, MSN; PENCE, CATHERINE RN, CCRN, MSN, Assistant Professor of Nursing Miami University Hamilton, Ohio (MCERLANE), Assistant Professor of Nursing Good Samaritan College of Nursing Cincinnati, Ohio (PENCE). Prepare and administer oxygen supplementation as needed. Certain medications may be prescribed to prevent further damage. Posterior bleeding, which is less common, may be more difficult to control. She found a passion in the ER and has stayed in this department for 30 years. Dimethyl Maleate And Dimethyl Fumarate, Ashley Furniture Head-foot Model-good King Adjustable Base, Kichler Landscape Lighting Replacement Bulbs, nursing care plan for epistaxis nurseslabs, ING Bank Voice Customer Care Enthusiast program flexibil 4, 6 sau 8 ore. AFib or AF is a commonly used abbreviation for the heart condition known as Atrial Fibrillation.AFib is the most common type of heart arrhythmia. Assess for signs and symptoms of hemodynamic instability, including change in mental status, pallor, diaphoresis, hypotension, tachycardia, and tachypnea. Medication. (Specific Systems) University Wallace Community College Selma Course Nursing Concepts 2 (11193) Academic year2021/2022 Helpful? Medication. Expected Outcomes: Therefore, our team will give you the ease in finding the correct Nursing Care Plan for Epistaxis. Here are six (6) nursing care plans (NCP) for Kawasaki Disease. The two types of clotting factor products include plasma-derived concentrates and recombinant factor concentrates. Good tissue perfusion is often characterized by the presence of good pulses in the femoral, popliteal, posterior tibial, and dorsalis pedis region. Monitor vital signs and neurological status. The consent submitted will only be used for data processing originating from this website. RN, BSN, PHN Bowel Obstruction (intestinal obstruction) is a condition wherein there is a blockage that prevents food or fluid from entering either the small intestines ( small bowel obstruction ) or the large intestines. Splenectomy or the removal of spleen was the recommended treatment for ITP and steroid-refractory thrombocytopenia; however, the advent of new treatments such as thrombopoietin receptor antagonists renders splenectomy as one of the last resorts for the treatment of ITP. Already a member? Anticipate that the physician my put the patient in an NPO or nothing per orem/ nothing by mouth status as ordered. Conditions that affect the function of the bone marrow can also cause low platelet count. Continue with Recommended Cookies, Ineffective Tissue Perfusion NCLEX Review and Nursing Care Plans. The endoscopist can diagnose and treat bleeding peptic ulcers while the patient undergoes endoscopy. Vitamin K is currently used for warfarin overdose.Protamine sulfate is currently used for, Decreased quantity or quality of circulating platelets in the blood (such as in, Interference in the genetic expression of clotting factors (such as hemophilia), Increased number of platelets (such as in immune thrombocytopenic purpura or ITP), Reduction of the bone marrows capacity to produce platelets (such as in blood cancers), Liver impairment or other conditions where there is a decreased rate in the synthesis of clotting factors, Gastrointestinal disorders such as peptic ulcer disease (PUD) and inflammatory bowel disease (IBD), Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), systemic anti-cancer therapy agents (SACT) may cause bone marrow suppression, Some herbal remedies that can affect clotting factors, such as ginseng and gingko biloba. Keep the patient's mouth moist while the packing is in place. * Put on protective gear, including gown, gloves, and goggles. The most common ones are IV heparin, subcutaneous low-molecular weight heparin (LMWH), and oral warfarin. * Continue to monitor vital signs closely. Adapted and updated from Rushing J. Problems in clotting factors in medical conditions such as hemophilia put the patient at risk for bleeding. The nasal packing will be left in place for 3 to 5 days. We use cookies to ensure that we give you the best experience on our website. Nursing Diagnosis: Risk for Bleeding related to decreased clotting factors in the circulating blood secondary to hemophilia. Decreasing levels will help physicians decide whether. To monitor the patients blood pressure levels as hypertension can worsen kidney damage. St. Louis, MO: Elsevier. Nursing diagnoses handbook: An evidence-based guide to planning care. Prevent straining such as when passing stool. Over 150+ nursing care plans for different diseases and conditions. 3. Individualized care plans are tailored to meet the unique needs of a specific client or needs that are not addressed by the standardized care plan. Monitoring of the patients neurological status may include measurement of GCS, level of consciousness, pupillary reaction, and muscle strength. Nexus Auto Transport Iskustva, Bowel Obstruction Nursing Diagnosis and Care Plan by Anna Curran. Administer blood transfusion as prescribed. You have entered an incorrect email address! Prepare the patient for splenectomy as indicated. St. Louis, MO: Elsevier. Increased destruction of platelets. As a nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process, break down complicated topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing concepts effectively. Prepare the patient for the surgical procedure as indicated. Nursing Diagnosis: Fatigue related to post surgical removal of spleen secondary to thrombocytopenia and splenomegaly, as evidenced by verbalization of lack of energy, verbalization of tiredness, and generalized weakness. Wolters Kluwer Health Please try after some time. Blood transfusion may be required if there is too much blood loss. - January 21, 2018 Modified date: July 17, 2021 Fracture is the discontinuity or breaks in the bone which is usually accompanied by trauma to the surrounding tissue. St. Louis, MO: Elsevier. Abnormal vital signs can signify changes in tissue perfusion. Know their pathophysiology, interventions, goals, and assessment in this database. Bring Back My Queens!, To measure the risk of bleeding by having a baseline of the platelet counts and coagulation levels of the patient. Encourage the patient to increase oral fluid intake. Epistaxis. Increased blood viscosity is a contributory factor to clotting. * Don't leave the patient unattended during epistaxis. If packing is used, especially posterior packing, monitor for respiratory compromise. To replenish the fluids and electrolytes lost, and to promote better blood circulation around the body. * Don't underestimate the amount of blood that can be lost from epistaxis. Ineffective tissue perfusion can cause some mild to serious medical conditions and complications. Manage Settings To increase the hemoglobin level and treat. Ask the patient to rate fatigue level (mild, moderate, or severe fatigue). 4 Real World Examples of Using Clinical Judgement to. Low blood pressure, low temperature, and dizziness may result from excessive bleeding. Fracture Nursing Care Plans 11 Nursing Diagnosis - Nurseslabs Nursing study notes for nurses. Nursing Care Plans Download these FREE nursing care plan examples for different conditions. It is the largest of the tree-dwelling mambas. His goal is to expand his horizon in nursing-related topics. Nursing care plans: Diagnoses, interventions, & outcomes. Regional sympathetic block or ganglionectomy can be done surgically to promote vasodilation and improve blood ow. To gain useful information before modifying the patients environment. Electrolytes may need to be replaced intravenously. Administer supplemental oxygen as ordered. Anti-fibrinolytics are drugs that stop plasmin activity, helping the clot to stay in place. To assess the fluid volume status of the patient. Nursing Care Plan Definition It is a collection of fluid in the pleural space of the lungs. Encourage progressive activity through self-care and exercise as tolerated. These tests are used to distinguish bleeding from the gastrointestinal or urinary tracts that may not be visible. Desired Outcome: The patient will demonstrate no further deterioration. Gastrointestinal disorders(e.g., varices, polyps ,ulcer) 5. Students also viewed Mat Health Chap 16 Objectives . Measles Nursing Diagnosis and Nursing Care Plan, Transient Tachypnea Nursing Diagnosis and Nursing Care Plan. We have placed these care plans online so that nursing students (and pre-nursing students) can get an idea of how care plans are created, and what care plans will . Evans JA, Rothenhaus T. Epistaxis. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. 2007. http://emedicine.medscape.com/article/764719-overview. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Desired Outcome: To prevent any bleeding episode while the patient is on anticoagulant therapy. Article by Nurseslabs. Nursing. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. Student BMJ. Nursing Diagnosis: Risk for Bleeding related to anticoagulant therapy. Educate the patient about avoiding tampons, vaginal douche, enemas, rectal suppositories, and other invasive medications or devices. Advise her to take steps to prevent constipation and straining, which increases the risk of bleeding. * Instruct the patient to avoid exerting herself, forcefully blowing her nose, or bending over during the first 24 hours. These anti-fibrinolytics are usually given as prophylaxis for female hemophilia patients with heavy menstrual bleeding, or for those who are schedule for dental work. The specific laboratory values to be monitored will depend on the patients specific clinical condition. There are several ways for the patient to help his/her wound to heal and improve tissue perfusion. Tell her to spit blood into the basin if necessary. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. If she has posterior packing, she'll be admitted to the hospital. Recommend switching from IV anticoagulant to subcutaneous or oral anticoagulant to the doctor when the therapeutic range has been reached. 1. Give clear fluids only if tolerated. Although the relationship between tobacco use and Buergers disease is unknown, smoking cessation still proves to be the main intervention to manage the disease. Desired Outcome: To prevent any bleeding episode and improve platelet count. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Depression Nursing Interventions Nursing Journal. Perform the necessary blood tests as ordered. If you would like to change your settings or withdraw consent at any time, the link to do so is in our privacy policy accessible from our home page.. Nursing Care Plans for Osteomyelitis Acute Pain r/t infectious process and swelling Expected Outcome: The patient will report an acceptable pain level of 3 or less on a 0 to 10 pain scale, as evidenced by vital signs within normal limits and a relaxing effect and body posture. Nose bleeds are mostly caused by too much heat. Risk for Bleeding Nursing Care Plan 1 Surgery Nursing Diagnosis: Risk for Bleeding related to invasive surgical procedure Desired Outcome: To prevent any bleeding episode during or after the surgical procedure. The client with epistaxis usually arrives at the emergency room following unsuccessful attempts to stop the bleedingsigns of airway obstruction. 3 Nursing Diagnosis for Epistaxis with Interventions and. (2020). Adequate hydration helps reduce blood viscosity. Low blood pressure, low temperature, and dizziness may result from excessive bleeding. Any invasive procedure such as surgery can put the patient at risk for bleeding. Use a soft-bristled toothbrush and nonabrasive toothpaste. Jill Rushing is a nursing instructor at the University of Southern Mississippi in Hattiesburg. Delayed wound healing is very common in patients with peripheral vascular disease. Perform the blood transfusion if indicated. 2009;39(6):12. Although it rarely poses a life-threatening hazard, it may still give parents of young children cause for serious concern. Kichler Landscape Lighting Replacement Bulbs, In cases of. To help the patient or the guardian take ownership of the patients care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. If you continue to use this site we will assume that you are happy with it. Teach the patient or caregiver pinching pressure techniques. St. Louis, MO: Elsevier. Nursing care planning and management for patients with glaucoma include: preventing further visual deterioration, promoting adaptation to changes in reduced visual acuity, and preventing complications and injury. * Obtain a history about previous nosebleeds, other bleeding episodes, easy bruising, and medication use, especially use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, warfarin, and herbal products. Plasmapheresis. Desired Outcome: To prevent any bleeding episode during or after the surgical procedure. Surgery. To monitor patients fluid volume accurately. Protamine sulfate reverses the effect of heparin. An example of data being processed may be a unique identifier stored in a cookie. If cautery is unsuccessful, nasal packing will be used to apply direct pressure to the bleeding site. She found a passion in the ER and has stayed in this department for 30 years. NANDA Nursing . Tell her to spit blood into the basin if necessary. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. Care plans can be informal or formal:Informal nursing care plan is a strategy of action that exists in the nurses mind. 2008. Patient on anticoagulant therapy remains at risk of developing emboli. Start intravenous therapy as prescribed.
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