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By Gretchen Remolador And friends from Ward 3A

y Malignant tumor of the larynx is also known as laryngeal cancer. Cancer of the

larynx accounts for 2% to 3% of all malignancy and presents as malignant ulceration with underlying infiltration and is spread by local extension to adjacent structures in the throat and neck, and by the lymphatic system. Laryngeal cancer is classified and treated by its anatomic site. Cancer of the larynx (voice box) may occur on the glottis ( true vocal cords), the supraglottic structures ( above the vocal cords) or the subglottic structures (below the vocal cords). y There are an estimated 10,600 new cases of laryngeal cancer each year, most occurring in men and it is thought that older men are more likely to develop laryngeal cancer than women because the two main risk factors for acquiring the disease are lifetime habits of smoking and alcohol abuse. More men smoke and drink more than women, and more African-American men are heavy smokers than other men in the United States. However, as smoking becomes more prevalent among women, it seems likely that more cases of laryngeal cancer in females will be seen and the incidence of cancer of the larynx in women is increasing. If untreated, cancer of the larynx is inevitably fatal; 90% of untreated people die within 3 years. Like other cancers; however, it is potentially curable if discovered early enough.


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GENERAL OBJECTIVES To conduct a thorough and comprehensive study about Mr. C, H. disease according to the data that was gathered by conducting a series of interviews and extensive research.

SPECIFIC OBJECTIVES To define was is Laryngeal Mass ( tumor) Identify the etiology/ causative factor of such disease. Trace the disease process from the cause to the clinical and classical manifestations presented by the patient case. To establish Nursing Care Plan applicable for the patient. Discuss the appropriate nursing management for the patient care. Explain the medication, mode of action and nursing considerations applicable to the patients complains. Appreciate the effects of the patient s situation before and after surgical management to his physical, mental, emotional and spiritual aspects of his life. To construct a discharge plan following the METHODS format. To compose relevant recommendations extracted from our case study. To modify diet and lifestyle promoting health against further worsening of the disease. To recognize patients situation and develop correct knowledge and attitude towards the disease. To maximize patients functionality despite having the disease.


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Client C, H is an 80 years old, male, Filipino, and a widower. He was born on April 13, 1930 at Minglanilla Cebu. He is a retired Seaman and his religion is Iglesia ni Christo. The main reason of seeking health care is that he finds it hard to communicate and disrupting when he talks, and he stated that he wants it to be cured. . Past Illness and hospitalizations. Client had Pediatric illness like chickenpox when he was in grade 3, and mumps when he was in grade 5. Client cannot recall the medications given but the illness has relieved. He has not undergone surgeries and stated that he has completed all vaccinations given during childhood. Allergies: Client is not known to have allergies on food and drugs.

Family history Patient was abandoned by his parents when he was 13 and had been living with his grandparents since then. Hypertension and asthma can be traced on his maternal side and pneumonia on his father s. However, both of his parents did not die for such diseases. His mother died of dehydration as a complication of diarrhea and his father s cause of death was not clear to him although he was a known alcoholic.

y C. Social and Personal history y Client is a retired seaman with a daughter who now works in the Middle East as a nurse. He admits being an alcoholic consuming about 5-10 glasses a day when he was still young around 17-30 years old. He used to be a smoker consuming 10-15 stick per day though he has quitted smoking since 1997. Apparently, the group of people he socializes makes him a 2nd hand-smoker. He often eats vegetables and seldom eats meat. He is now living by himself with his dogs. He is a very religious man he keeps on praying every morning, afternoon and evening in his church.

D. Review of systems

Blurring of vision Sore throat Thirst Neck pain Joint pain Headache Voice change Depression


Difficulty swallowing Back pain




History of present illness:

y Three months prior to admission client experienced

onset of hoarseness, and does not sought consultation and no medication taken. About 3 weeks before his admission client experienced symptoms like cough and colds, fever and took kamilosan spray. Due to persistence of condition thus prompted this admission.

y Assessed client sitting on bed awake, conscious,

coherent, responsive with the following vital signs; T=37.8 degrees Celsius, P= 74 BPM, R= 20 CPM and BP of 120/80 mmhg. Appearance and mental status: Relaxed erect posture; coordinated movement; clean and neat; no body odor; no distress noted; cooperative; clients affect and mood is appropriate to situation.




walay mga sakit-sakit, maayo and lawas as verbalized by the client. Client described his current condition as 6 in a scale of 1-10 (as 10 as the highest score). He only sought medical attention when experiencing severe illness, not manageable by self medication. His usual over the counter drugs are pain reliever such as Mefenamic acid and Paracetamol as for fever. He sometimes used herbal plants like guava for cleansing of wound and cough remedy as an alternative medicine. NUTRITION & METABOLISM PATTERN. Client takes 3 full meals per day consisting of rice, vegetables, fish, and sometimes canned goods. He likes to eat dried fish and anchovies as an appetizer and he stated that his meal is incomplete without this. He seldom eats pork and beef as a meat due to his religious restrictions. He also eats fruits like banana, avocado and etc. He doesn t follow any certain type of diet and has never taken any vitamin as supplements. He has not experienced problems or difficulty eating foods. He drinks water at least 3- 5 glasses everyday. He drinks alcohol beverages about 5-10 glasses consumed in a day when he was still young and stop drinking alcohol around 30 years old due to religious restrictions. He was a smoker and consumed 10-15 sticks per day, but he quit smoking since 1997. During the present illness patient s appetite reduces due of difficulty swallowing and eating large amount of foods. Client reported that he lost weight about 8-11 pounds.

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Client s usual bowel pattern occur everyday, color and consistency of stools was sometimes dark yellow and dark brown and moderately soft and watery. He seldom experiences constipation. He urinate 4-6 x a day with yellowish urine. He never experience difficulties or problems upon urination and defecation. y During hospitalization he only defecate every other and urinates 4-6 times a day without any difficulty.


The client s routine exercises include jogging and walking around the backyard. He used to lift heavy objects when he was still in work. And now his activities include reading bible, news paper, watching television and talking with his friends, he also went to malls, to his friend s house and to his church.
y 5. CONITIVE AND PERCEPTION y Senses are intact; able to feel heat and cold weather; able to answer

question appropriately and coherently to the questions given; able to read and write with the use eye glasses. Client is a college graduate; He is able to speak, English, tagalog and cebuano language fluently. He is able to remember past and recent events that are only significant. This present illness causes him difficulty to express/communicate verbally to his friends and relatives.

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Client s usual sleeping time at home is around 8-9 pm & wakes up at 4-5am; usually have pillows as sleeping aid. He has not experienced difficulty falling asleep. No medication, food & beverages taken before going to sleep. During hospitalization client experienced interruptions while sleeping.

y y SELF-CONCEPT AND SELF- PERCEPTION y Client claimed that his responsible and honest. He considers God and his family y

as his strength and his weakness. He accepted his condition and worried at the same time.

y y COPING AND STRESS TOLERANCE y He considers his current health condition as the most stressful event in his life. y

The second one is his disagreement with his only daughter. When he has problem he always pray fervently to God. Most of the time he talks to his friends about his problem

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Client is living alone. He is responsible to his actions he has a good relationship to his daughter and friends.

y y 10. SEXUALITY AND REPRODUCTION y Client was sexuality active until he became a widower. He has one y


y y y 11. VALUES AND BELIEFS y Client s religion is Iglesia ni Christo. He always goes to his church y

and attends prayer meetings.


The larynx is located where the throat divides into the esophagus and the trachea. The esophagus is the tube that takes food to the stomach. The trachea, or windpipe, takes air to the lungs. The area where the larynx is located is sometimes called the Adam's apple. The larynx has two main functions. It contains the vocal cords, cartilage, and small muscles that make up the voice box. When a person speaks, small muscles tighten the vocal cords, narrowing the distance between them. As air is exhaled past the tightened vocal cords, it creates sounds that are formed into speech by the mouth, lips, and tongue. The second function of the larynx is to allow air to enter the trachea and to keep food, saliva, and foreign material from entering the lungs. A flap of tissue called the epiglottis covers the trachea each time a person swallows. This blocks foreign material from entering the lungs. When not swallowing, the epiglottis retracts, and air flows into the trachea. During treatment for cancer of the larynx, both of these functions may be lost.

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y 3/8 y Patient was admitted at exactly 7 o clock in the afternoon. y D- Received pt. trans-in from ER ambulatory with chief complains of hoarseness of Voice y A - Ushered patient on bed y Follow-up procurement of pre-operative medication and materials y Scheduled patient for elective surgery as indicated. y Secured consent y Secured laboratory exams. y Reinforce patient status. y follow-up intern for IV insertion

y 3/9 y 7 am For OR y D seen patient on bed, awake, with IVF of D5NSS infusing well, for tracheostomy / local anesthesia and punch biopsy, rigid endoscopy under general anesthesia, wit complete materials and Pre-op medications. y A referred BP 180/100 to Dr. Gadrinab, started nicardipine drip 10 mg + 20 cc D5 Water at 6:15am, vital signs taken and referred to Dr. Antolin, pre operative medications given, ensured NPO is maintained, checked consent, referred to OR NOD for transport y R transported to OR with the following vital signs: BP= 140/80, T= 35.7, P= 80, R= 20

y 7:30 am For tracheostomy y D received patient from ward per stretcher, conscious, coherent, and responsive, with consent for operation, with IVF of D5NSS 800 cc with piggyback of nicardipine drip 75 cc at 20 cc per hour infusing well at left arm y A identified patient, checked consent, OR rable prepared aseptically, transferred patient to OR table in supine position, anesthesia inducted by Dr. Vina Lastimosa under general anesthesia, skin preparation done and draped patient aseptically, operation started by Dr. Earl Dimerin, anticipated surgeon s needs, maintained sterility throughut surgery, operation ended, assisted in wound dressing y R extbated patient, wheeled to PACU, with trachea inserted well , with IVF infusing well, endorsed to NOD.

y 9:50 am Post transport PACU notes y D from OR per stretcher, with IVF of D5NSS 800 cc with piggyback of nicardipine drip 75 cc at left arm closed, sedated, with tracheo y A administered O2 inhalation via T piece to trachea tube at 6-8 lpm, provided comfort and safety, maintained on NPO y R transported to ward, with IVF, awake, conscious, responsive, with trachea to T piece, ward NOD informed, vital signs as follows: BP= 130/80, T= 36.3, P= 67, R= 18

y 3/12 9am Airway patency y D received patient lying on bed, awake and coherent, with IVF infusing well at 30 drops per minutes at left arm, with tracheo, frequent coughing noted, presence of thick mucoi secretions at trachea tube, vital signs as follows: BP= 120/80, T= 36.8, P= 95, R= 25 y A monitored respiratory rate, auscultated breath sounds, elevated head of bed, encouraged effective coughing and deep breathing exercises, suctioned secretions, trachea care done, encouraged ambulation y R airway patency maintained with RR at 22 bpm

y 3/14 10 am Ineffective airway clearance y D received patient lying on bed, with tracheo, with IVF infusing well, with secretions at neck, noisy breath sounds y A vital signs taken, suctioned secretions as needed, needs attended, trachea care done, provided comfort measures, chest physiotherapy done

y 3/15 10 am Impaired verbal y D received patient sitting on bed, awake, afebrile, no audible sounds noted, with trachea y A instructed patient to write in a piece of paper if he has anything to say, needs attended, spoke to patient in a slow and normal tone, suctioned secretions as needed, trachea care done, due meds given, checked and regulated IVF y R seen patient cooperating by writing down what he wants to say

y Tramadol 50mg IVTT y IND: Moderate to Moderately Severe pain] y CI: hypersensitivity to drug and its component, use cautiously in patient at risk fro seizure or respiratory distress, with increase ICP or head injury. y SE: -Diarrhea, nausea, vomiting, urticaria, vaginitis y SC: -determine previous hypersensitivity reactions to penicillins, and other allergens to therapy y monitor for any signs of hypersensitivity e.g urticaria usually occurring within few days after start of drug, or fever, dyspnea and report to physician accordingly y check vital signs accordingly during start of therapy to assess some allergic reactions manifested

y Acetylcysteine 1 neb every 12 hrs y IND: treatment of respiratory affections characterized by thick and viscous hypersecrestions acute and chronic bronchitis and its exacerbation, pulmonary emphysema, mucoviscidosis, and bronchiectasis. y CI: hypersensitivity to drug, phenylketonuria that contains aspartate. y P: Newborns (Phenylketonuria) and asthmatic patient, and also with history of peptic ulcer disease. y SE: diarrhea, pyrosis,n/v, urticaria, and bronchospasm. y SC:monitor for S&S of aspiration of excess secretions and for bronchospasm (unpredictable); with hold drug and notify physician immediately y Have suction apparatus available, encourage increase fluid intake, suction secretions may needed to establish and maintain open airway y Instruct patient/ S.O to report for any signs of respiratory distress

y Co- Amoxiclav 625mg 1 tab BID PO y IND: treatmet for URTI and LRTI, GUT infection, soft and skin tissue, bone and joint infection and other infection. y CI: possible cross sensitivity with other beta-lactam antibiotics, history of penicillin associated with jaundice or hepatic dysfunction. y P: liver or renal dysfunction or cholestatic jaundice, anaphylactic reaction,. y SE: GI disturbance

y Clonidine 150 mg tab SL slow y IND: Hypertension y CI: Pregnancy, lactation y SE: -hypotension, postural hypotension, peripheral edema, flushing, drowsiness, headache, fatigue y SC: -Give last P.O dose immediately before patients sleeps to ensure overnight BP control and to avoid daytime drowsiness y Instruct patient not to abruptly discontinue drug, abrupt withdrawal may resembles sympathetic stimulation that leads to restlessness and headache 2-3h after miss dose and Hypertensive crisis 8-18h y store in tightly closed container at 15 degrees to 30 y check BP after 30 mins. After administering drug to evaluate therapeutic response and to check for any signs of hypotension


Kolcaba s Comfort Theory Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence. Also, Kolcaba described 4 contexts in which patient comfort can occur: physical, psychospiritual, environmental, and sociocultural. Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence. If specific comfort needs of a patient are met, for example, the relief of postoperative pain by administering prescribed analgesia, the individual experiences comfort in the relief sense. If the patient is in a comfortable state of contentment, the person experiences comfort in the ease sense, for example, how one might feel after having issues that are causing anxiety addressed. Lastly, transcendence is described as the state of comfort in which patients are able to rise above their challenges








PROBLEM: Ineffective airway clearance r/t to excessive secretions as evidence by wheezes. CUES y Subjective: no verbal cues y Objective : - weakness observed - ineffective cough with excessive yellowish mucopurulent secretions, - With tracheostomy attached to t-piece at 4-6 LPM - wheezes upon auscultation. ANALYSIS OF THE PROBLEM: The flow of air through a tracheostomy tube may become occluded for several reasons. The tracheostomy tube may be misaligned so that its opening lies against the tracheal wall, preventing air flow. Cuff over inflation causes the cuff to herniated over the tip of the tube, obstructing air flow. Without adequate airway care, the inner cannula can become occluded with dried secretions or excessive bronchial secretion. STATEMENT OF PATIENT CARE OBJECTIVES: y Short term: Patient will have an effective airway clearance after an hour of intervention. y Long term: Patient will be able to demonstrate behaviors to improve and maintain airway clearance.




Independent Function: - Placed patient on moderate high back -To take advantage of gravity decreasing rest. on the diaphragm and enhance drainage. -Suction secretion as needed -To clear airway when secretions are blocking airway. -Provided chest physiotherapy every after -To help loosen secretions nebulazation. -Auscultated lung sound frequently. - To determine presence of secretion -Monitored patency of IV tubings -To avoid fluid overload and underload. frequently, regulating IVF at its prescribed rate. -Monitored vital signs -To assess changes and note -provided information about the need to complication. expectorate secretion versus swallowing it. - Instructed patient to cough into paper -To examine and report changes in the tissue and dispose them properly. color and amount. - Instructed to performed Deep breathing -To expectorate and avoid infection. exercise Dependent functions: -Administered oxygen therapy as -To promote respiration indicated. -Administered medication as prescribed. - To reduce hypoxemia Such as acetylcysteine -To thin secretions and promote Interdependent/ collaborative functions: respiration. - Watched out for unusual ties and refer - To prevent further complication to physician.

Patient s airway was clear as evidence of no more noisy respiration sounds. Seen patient following to the instructions given by coughing with the use of tissue paper.


y Problem: Risk for infection r/t post-operative site secondary to tracheostomy. y Cues : Intact and patent tracheotomy site.
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Excessive yellowish mucopurulent secretions noted Wheezes noted

y Analysis of data: Tracheostomies increase the risk of bronchopulmonary infection

because they bypass upper airway protective mechanism (i.e., filtering, warming and humidifying) and it decrease mucociliary transport and coughing, thus increasing retained secretion. Stoma site infection may occur as well. Nosocomial infection is also a potential sterile therefore all solutions and equipment entering the trachea must be sterile.

y STATEMENT OF PATIENT CARE OBJECTIVES: y Short term: Patient s tracheostomy site will remain clean and patent after an hour of intervention. y Long term: Patient will exhibit no indication of infection like absence of fever, dry and clean tracheostomy site, and clear secretions.

NURSING ACTIONS Independent Function: -Clean the tracheostomy site using aseptic technique by handwashing, using sterile gloves and sterile supplies. -Changed dressing as needed. - Inspected the skin around the stoma for signs of redness, inflammation and irritations. -Suction secretion as needed Dependent functions -Due medication given on time such as 1. Co-amoxilav antibiotic. -Administered medication as prescribed. Such as acetylcysteine -Administered O2 as prescribed Collaborative functions: - Watched out for unusual ties and refer to physician.



-To reduce contamination microorganism.

of Tracheostomy site was free from infection as evidenced by absence of fever, clean and dry dressing, clear secretions, and no signs of -Because Damp or mucus-soaked inflammation. dressing constitute a perfect medium for the growth of microorganism -To detect early signs for infection -To avoid excessive formation of mucus. -Drug may inhibit synthesis of bacterial growth. -To thin secretions and promote respiration. - To prevent further complication.



PROBLEM: Impaired verbal communication related to the presence of tracheostomy tube.


CUES: y Subjective: No audible verbal cues


Objective: Received patient on lying on bed awake, a febrile and non dyspneic, difficulty producing speech or sound, facial tension observed upon speaking, active listener, vocalizes inaudible sounds in attempt to communicate, with tracheostomy attached to t-piece at 4-6 LPM.

ANALYSIS OF THE PROBLEM: Human communication takes many forms. Person usually communicates verbally through the vocalization of a system of sounds. Humans communicate through touch, written means, sometimes a combination of all the system listed. Communication implies the sending of information as well as the receiving of information. When impairment of means of communication such as the presence of tracheostomy, communication ceases & the message ceases to the sole clarification of the points originally transmitted; resulting from being possibly compromised. STATEMENT OF PATIENT CARE OBJECTIVES: Short outcome: Patient will be able to use a form of communication to get his need met after an hour of communication. Long term: After a week of intervention patient will be able to communicate using several forms of communication to relate effectively with the people.

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-To establish trust and cooperation. -To make a clear flowing conversation and to easily comprehend. - To save time and energy in patient s behalf. -Spoke in normal tones and avoid -To give ample time to respond. speaking to fast -Provided alternative methods of -To express feeling in a simpler means. communication; body movement., visual cues & gestures. - Listened carefully and attended patient -To render intervention easily and correctly. needs. - Told patient to write it in a paper if his -To clarify things and meet patients needs. message is not understood. Dependent functions: -Medication given as prescribed such as -To thin secretions and promote respiration. acetylcysteine. -To avoid infection. - Tracheostomy care done Interdependent/ collaborative functions: - Watched out for unusual ties and refer - To prevent further complication. to physician

Independent Function: - Introduce self and build rapport -Talked directly to patient and speak slowly. -Used yes or no question to begin with

After an hour of bedside care and nursing intervention patient seen doing hand gesture and nodding of head in attempt to deliver response of information given. After a week of continuity of care patient seen following what is instructed for his treatment regimen. Used an update through paper for the nurse to see and seen conversing a lot more than usual.


Date Implemented Time frame Health Teaching based on the Concept of METHODS OUTCOME

M- Instructed patient to take bring home medications. ( Co- amoxiclav 625 tab 2x a day) religiously - Instructed patient and significant other to avoid discontinuation of the regimen to achieve the optimum effect of the drugs prescribed. - Explained the rationale for taking the medication as prescribed. E- Home environment should be adequate for care and safely. - Environmental modification should be done for patient s safety. -The patient is advised to stay in an environment wherein cleanliness is valued and practiced. - Significant others are encourage to take in watching the patient in case the patient needs assistance in some of the ADLs. - Practice proper sanitary disposal garbage. T- Referred to Physician for follow-up check-up - Encourage reinforcement of appropriate and effective coping strategies. - Instructed significant others to provide patient water for drinking, bathing and washing clothes free from contamination. H- Activities of daily living should be modified according to patient s capacity. SO s should render safe techniques to assist patient with selfcare hygiene and feeding. - Emphasized the importance of quality rest. O- Instructed patient to report different changes like difficulty of breathing, pain on swallowing, changes in voices - stressed the importance of continuing on follow-up health care plan. D- Encouraged to eat nutritious foods esp. those are rich in iron and Vit. C -Instructed patient to eat soft foods to avoid straining or irritating the throat. - Promoted the importance of increasing fluid intake, at least 8-10 glasses of water to avoid constipation. S- Encouraged patient to keep praying religiously.

Through this study, we have just known and appreciate the real meaning of having basic knowledge, skills and positive attitude in the field where we are right now. Knowledge is very important since we will not only deal with persons alone but also with machines which will be part of saving millions of livers. Aside from being skillful and knowledgeable, we nurses must possess positive attitude though we cannot please all our patients, but still we need to be humble no matter how intense or tough the situation may be. Being knowledgeable, skillful, and having positive attitude we will be able to gain trust from our patients. We have realized that attending immediately to the needs of our patients is one effective tool towards achieving health care goals. We have learned that providing privacy to our patients is an essential part of patient care. Providing privacy to our patients is one factor that affects the helping and therapeutic relationship between the nurse and the patient. By establishing an open communication, trust, confidence with the patient, nursing therapeutic relationship maintained, thus contributing to the effectiveness of nursing interventions. Another learning we had regarding patient care is that, patients tend to be cooperative and gain confidence when they see the angel in us. Patients disease conditions most of the time have low self esteem, talking to them and doing things for them will be of great help in boosting that esteem. As our recommendation, we encourage the Staff Nurses to read to broaden knowledge, gather information and most of all practice what they have learned about all aspects of human life. Since we will be dealing with different persons with different personalities and preferences, as nurses, we need to be sensitive to their needs and learn from them. We encourage them to put not only in their mind what they have learned but also in their hearts. Because once it s in their nobody could steal this from them and this is only weapon to render appropriate and quality care to our patients.


The primary focus of the nursing profession (both nurses and nurses trainees) in this institution (VSMMC) is the quality of health care for all. To this end, I believe that the comprehensive recommendation developed by this case study will ensure that VSMMC has a solid foundation of nursing services to meet health needs of the patients in the 21st century.

TO THE HOSPITAL While conducting this case study, I m aware that there may be areas of urgent need. In the short term, I strongly recommend that a comprehensive investment in the nursing sector be made across the spectrum of the health care delivery system to enhance the quality and continuity of health care. This investment for health care consumers will include. y Reduce hospital admission y Less frequent emergency room visit s y Reduce stress for those caring for family members at home as well as enhanced accessibility to nursing services. TO THE STAFF NURSES AND TRAINEES y In general, it is recommended for nurse trainees to know how to perform all their responsibilities with the utmost accuracy and detail. The primary responsibilities of a nurse usually include knowing and understanding the health needs of the patients, performing initial and sometimes frequent evaluations, and performing basic procedures. Nurse trainee should also refine their skills over time. In doing so, their responsibilities may increase. Additionally, to stay sharp, many nurses participate in continuing education classes to stay informed on new disease, drugs and techniques for patient care. By constant practicing and learning, a great nurse develops and displays in her medical knowledge.