EBP - Nursing Plan - Nursing Internship in Kenya
Case
Name: Jana Djonsi (*fictive name)
Sex: Female
Marital state: married
Date of birth: 01-01-1966, 48 years of age
Address: Nairobi Kenya
Admitted: 19 of September 2014 at ICU
Reason of admission: Stroke
Medical history:
- Tested HIV positive (1982)
- Tb infection treated (1998)
- Broken leg (1978)
- Six pregnancies (one born dead, five born healthy)
Vitals: BP 130/80, BM 76, Temp.:36.8, Saturation: 98%
Mrs. Djonsi had a stroke on the 19th September and was admitted to the ICU at Coptic hospital. She is 48 years old. Due to the stroke she is almost completely paralysed. Mrs. was admitted to the ICU because she is unstable. Mrs. is infected with HIV and has a tracheotomy tube . Because of respiratory problems mrs. Djonsi got the tracheotomy tube. Mrs. Djonsi is not able to feed, wash or take care of herself. Mrs. has five children. Three boys of 17,20 and 24 years old and 2 girls of 22 and 25 years old. Al the children went to school on their own. Now the children have to take over the fruit stand of Mrs. Djonsi because she cannot work anymore. Mrs. Djonsi has a husband he comes everyday to the hospital. Mrs. was a businesswoman and worked every day from 10.00 am un till 22.00pm at the market in South B she would walk every day for 30 minutes to her fruit stand. At the market she was very popular and every one would know her. She has her own fruit stand. Mrs. Djonsi lives in Nairobi with her husband and five children in a rental apartment.
11 heath patters of Gordon
1.Perceived health and conservation
Mrs. Djonsi is not always able to speak because of the stroke. Often, she is asleep. When she wakes up she can make clear with a few words. She doesn´t like to be in the hospital. She knows that because of the Hiv she can get very sick in the hospital and rather say at her own house. But in her house are not the supplies she needs. Mrs. Djonsi wants to take care of her own and does not want to be dependence. Because of the stoke mrs cannot swallow or breath very easily. She cannot wash or take care of herself on her own. She says she doesn’t want to be in this state and wants to get better. Mrs. Djonsi always lived a healthy life and thinks it is unfair that she had a stroke.
2.Nutrition and metabolic pattern
Mrs tries to eat thru her mouth but this is not working because she has trouble swallowing. Also if Mrs. Djonsi tries to drink se has trouble swallowing. Because of this fact mrs. Djonsi lost a lot of weigh. Her weigh was 75 kg and is now 68 kg. Mrs. Djonsi has a bladder catheter, she cannot walk or go to the toilet. She also has a canulla, thru this canulla she gets fluids and drugs. She has to take a lot of drugs due the Hiv infection and stoke. Mrs. Djonsi also has a tracheotomy because she has trouble breathing. Mrs. Djonsi does not want to take the drugs because her husband tells her not to.
3.Excretion pattern
Mrs. Djonsi says she is happy to have a bladder catheter because she cannot walk to the toilet. She also wears a diaper for her stool. Mrs. Djonsi did not had any stool for the last 4 days and says that her stomach hurts.
4.Activity pattern
Because of the stroke mrs Djonsi is not able to walk or move her arms and legs. She really doesn’t like to be in bed all the time because she was used to walk a lot to her fruit stand and the fact that she cannot do that anymore frustrates her. She did not have any other exercise during the week. She is not capable of taking care of herself. Mrs. Djonsi gets help every morning with bed bath and feeding. Mrs. Djonsi can also not turn herself in bed.
5. Sleep and rest pattern
Mrs. Djonsi sleeps a lot every day. The average hours she sleeps is twelve hours per day. When she is awake she is sometimes able to speak. Mrs. Djonsi says she is well rested when she wakes up.
6. Perception and cognition pattern
Mrs. Djonsi does understand what you are saying to her but cannot express herself easily. She tries to express herself with words and with her hand. She can smell and hear very good. Her eye vision is also good. She can feel pain and her memory is also present. Mrs. Djonsi’s face shows that she is in pain even though she says it doesn’t hurt to the nurses. She also doesn’t show it to her family and friends.
7. Self- perception pattern
She is aware that she is in this state but finds it hard to accept it. She constantly says that she doesn’t like to be in the hospital but tries to make the best of it. Mrs. want to take care of herself and her family and cannot accept this is not possible. She desperately wants to get better but understands that the percentage is very low. She says that she feels powerless now she cannot do anything on her own. She also says that she listens only to her husband because he knows what is best for her.
8. Rolls and relationship pattern
Mrs. Djonsi has a lot of children. Mrs. has five children. Three boys of 17,20 and 24 years old and 2 girls of 22 and 25 years old. She also has a husband. He visits her everyday if it is possible. She listens to everything what her husband want. What he demands she does . Her husband says the medicine are not good for her and that she better doesn’t take them. Her sons now run the market stand for mrs. Djonsi. Mrs. Djonsi has a lot of family members, every day during visiting hours one of the family members comes by. She has 3 brothers and 4 sisters. Often the sisters help the nurses with the caretaking. She cannot communicate well with her family and friends because she cannot express herself easily. She cannot speak good and it is hard to form words. She really would like to be on the market en talk to all her friend an colleges. She is upset that she cannot do this anymore.
9. Sexuality and reproductive pattern
We have no information about this pattern.
10. Stress processing pattern
Mrs. Djonsi handles her situation pretty good. She has hope for a bright future. She gets a lot of support from her family and friends. She thinks she is strong and does not want to give up. When mrs. Djonsi is awake she keeps herself busy with watching Kenyan soaps. She says that she feels powerless now she cannot do anything on her own.
11. Values and beliefs pattern
Mrs. Djonsi say’s her future is in God’s hands. She doesn’t like the life that she has now. Even though she doesn’t know what the future will bring her she doesn’t like the look of it. She is raised as a catholic girl and used to go to church every Sunday. Mrs. Djonsi prays every morning to God. She says God gives her a lot of power to keep on going she has no faith in the hospital and medicine but only in god.
Elaboration complexity scorecard
I scored the patient throughout a complexity scorecard ( Annex 2: complexity scorecard). With the complexity scorecard you can score the patient on different levels. The total score is 32, if the patient scores above 18 point the patient is middle to high complex. If the patient scores below 18 points the patient is low complex. Mrs. Djonsi had a score of 25 out of 32. This means that Mrs. Djonsi is a middle to high complex patient.
Mrs. Djonsi had this high score because she has several problems. She scored high on several points such as point; D and E she got 4 points on both numbers. These points score if the patient needs complex nursing materials and cannot feed, wash or take care of herself. She has a lot high complex nursing materials such as; IV’s, canulla’s, bladder catheter and tracheotomy tube. Also because she is paralysed she cannot take care of herself and needs a lot of care during the day. With numbers A,B,C,G and H she scored 3 point each. Point A is about the stability of the patient, she is stable or not. She is stable but there is a change she has a complication. This is why she scored 3 points on A. With point B you can score the patient is she can get a risky complication. Due to all the complex nursing materials there is a change she gets a complication. So also for this point she gets 3 points. On number C she also gets 3 points because there a several caretaking departments present. Mrs. Djonsi cannot communicate well this is why she scores 3 points for number G. And she also got 3 points for number H because the different deceases complicate one another. The only number where she scored low on was number F because she doesn’t need extra support of her wellbeing.
Sorting health patterns
| Health patterns | Nursing problems (potential) |
|
| 1. Perceived health and conservation Functional - Dysfunctional: Mrs. Djonsi is not always able to speak because of the stroke. Often, she is asleep. When she wakes up she can make clear with a few words. She cannot wash or take care of herself on her own. She says she doesn’t want to be in this state and wants to get better. | Potential nursing problems
Nursing Problems non |
|
| 2. Nutrition and metabolic pattern Functional Mrs. Djonsi also has a tracheotomy because she has trouble breathing. Dysfunctional Mrs tries to eat thru her mouth but this is not working because she has trouble swallowing. Also if Mrs. Djonsi tries to drink se has trouble swallowing. Because of this fact mrs. Djonsi lost a lot of weigh. Mrs. Djonsi does not believe the drugs will help her get better this is what her husband tells her. | Potential nursing problems - Decreased defence
- Dysphagia
Nursing Problems non |
|
| 3. Excretion pattern Functional Mrs. Djonsi says she is happy to have a bladder catheter because she cannot walk to the toilet. She also wears a diaper for her stool.
Dysfunctional Because she cannot eat properly Mrs. Djonsi didn’t had stool for the last 4 days. | Potential nursing problems
Nursing Problems
|
|
| 4. Activity pattern Functional - Dysfunctional Because of the stroke mrs Djonsi is not able to walk or move her arms and legs. She is not capable of taking care of herself. Mrs. Djonsi gets help every morning with bed bath and feeding. Mrs. Djonsi can also not turn herself in bed. She has a tracheotomy because she cannot breath on her own. | Nursing problems
Potential nursing Problems
|
|
| 5.Sleep and rest pattern Functional Mrs. Djonsi sleeps a lot every day. She says she is well rested when she wakes up.
Dysfunctional The average hours she sleeps is twelve hours per day. When she is awake she is sometimes able to speak. | Nursing problems Non
Potential nursing Problems non |
|
| 6. Perception and cognition pattern Functional Mrs. Djonsi tries to express herself with words and with her hand. She can smell and hear very good. Her eye vision is also good.
Dysfunctional Mrs. Djonsi does understand what you are saying to her but cannot express herself easily. She can feel pain. She says that she does has a lot of pain but she has learned that she cannot complain or show weakness. Mrs. Djonsi has a lot of pain even though she does not show it to her family and friends. | Nursing problems
Potential nursing Problems non |
|
| 7.Selff perception pattern Functional She desperately wants to get better but understands that the percentage is very low.
Dysfunctional She is aware that she is in this state but finds it hard to accept it. She constantly says that she doesn’t like to be in the hospital. Mrs. want to take care of herself and her family and cannot accept this is not possible. She says that she feels powerless now she cannot do anything on her own. | Nursing problems
Potential nursing Problems
|
|
| 8.Rolls and relationship pattern Functional Mrs. Djonsi has a lot of children. She also has a husband. He visits her everyday if it is possible. Often the sisters help the nurses with the caretaking.
Dysfunctional She cannot communicate well with her family and friends because she cannot express herself easily. She cannot speak good and it is hard to form words. She really would like to be on the market en talk to all her friend an colleges. She is upset that she cannot do this anymore. | Nursing Problems
Potential Nursing problems
|
|
| 9.Sexuality and reproductive pattern No information | - |
|
| 10. Stress processing pattern Functional Mrs. Djonsi handles her situation pretty good. She has hope for a bright future. She gets a lot of support from her family and friends. She thinks she is strong and does not want to give up. When mrs. Djonsi is awake she keeps herself busy with watching Kenyan soaps.
Dysfunctional She says that she feels powerless now she cannot do anything on her own. She doesn’t like the life that she has now. | Nursing Problems
Potential nursing problems
non
|
|
| 11. Values and beliefs pattern Functional Mrs. Djonsi say’s her future is in God’s hands. She says God gives her a lot of power to keep on going and never give up.
Dysfunctional Even though she doesn’t know what the future will bring her she doesn’t like the look of it.
| Nursing problems non
Potential nursing Problems Non |
|
Prioritising throughout Maslow
We begin at the lowest part of the Maslow pyramid. This part is the lowest part of the pyramid, according to Maslow this is the basic thing a human needs. If a human does not has it it cannot go higher in the pyramid. The first priority is pain. Mrs. Djonsi has a lot of pain even though she does not show it to her family and friends. This is a part of the lowest part of the pyramid so it has first place. It is also known that mrs.Djonsi does not eat well because she can’t. The second part of the pyramid is about physical security and sureness. Because Mrs.Djonsi cannot take part of the family at home anymore there is a disturbed family function also she cannot take care of her fruit stand anymore. At the third level it is all about togetherness, friendship and love. This level is complete and mrs.Djonsi has no problems with this. The fourth level is about status and socialise. And the fifth level is about self development. These last two mrs. Djonsi has no problems with she is only struggling with the first three. (Hesselink, 2010) (Carpenito)
Nursing problems
Pain
Swallowing disorder
Constipation
Deficit self-care
Inadequate therapy discipline
Social Isolation
Discomfort
Aspiration risk
Risk of suffocation
Risk of ineffective cough
Powerlessness
Decreased defence
Decreased mobility
Dysphagia
Disturbed family function
Disturbed roll playing
Inadequate speech
Disturbed communication
Infection risk
Elaboration problems
Pain
Inadequate therapy discipline
Dysfunction patterns
I will support the following text by literature and compare it with my own standards. The first elaboration problem is pain. Mrs. Djonsi says she is not in pain but you can tell from her face and body langue’s that she is in pain. Mrs. Djonsi was raised in a small village in the village she had to do a lot of hard work when she was younger. In the book ‘everyone thinks differ’ the auteur describes that values and norms are learned at a very young age and that they keep this for the rest of their life. (Hofstede, 2005). She had to work all day long and she could not complain. It was not normal to show weakness or pain. In the book ‘Foundations of intercultural communications’ the auteur describes the differentness about the expression of cultures. He describes that every culture has a different ways to express them self. So every body langue’s can be interpreted in different ways in every culture (Shadid, 2007). Because of the fact that Mrs. Djonsi learnt in her early years that she cannot show weakness or pain this is why she will also not show it in the hospital to the nurses or family.
When I was younger I would play a lot outside and would get hurt often by falling. When I had pain I learned always to tell or express myself. My mother would give me kisses and comfort me until the pain would go away. So I learned at a young age to express myself if I had pain or when I was feeling uncomfortable. Because of this fact that it was normal for me and in our culture to express myself, I continued doing this all my life. I am happy that I was raised like this and not have to be in pain if it can be treaded. Every time when I’m feeling sick and I do not know what it is I go see a doctor. In all the internship’s that I had the last years all the patient would complain about pain and ask for pain medication. We were always allowed to give the patient something against the pain. But I understand the life here in Africa is very different from ours. People have no time to be sick because they have to work. If you cannot work there will be no money for food. So this is also a meagre influence why the people do not complain or show weakness.
The second problem that I chose to elaborate is inadequate therapy discipline, this dysfunctional pattern is based on culture and religion. Mrs. Djonsi says that her husband knows what’s best for her and that she only listens to him. In the book ‘everyone thinks different’ the auteur describes that in every sociality there is inequality between people. In a country as Kenya there are big inequality between people. The high class has a lot of respect and the lower class doesn’t. The auteur of the book ‘everyone thinks different’ describes that in east- Africa they score high at the ‘large power distance’. This means that the high class people have a lot to say and privileges and the pore people have not much to say. Also there are a lot of income differences and corruption (Hofstede, 2005) . This also is shown in a family house hold, Mrs. Djonsi comes from a middle class/ poor family. The elderly have a lot to say about the young ones and decides what is best for them. Also in a marriage the man has a lot to say about the woman. The woman has to cook, clean, work and take care of the children and the man has also to work and make the most income. When the woman gets sick the man gets to decide what is best for their woman. The man is in east Africa very dominate this shows out of the ‘large power distance’ score (Hofstede, 2005). Because Mrs. Djonsi has learned from a early age that the man decides what is best for the woman she will not doubt the decisions that her husband makes. (Hofstede, 2005)
Nursing diagnoses
The following nursing problems will be elaborated with the PES structure.
Pain
Inadequate therapy discipline
Swallowing disorder
Constipation risk
Social Isolation
5.1 Pain
P: Acute Pain
E: HIV
S: Mrs. Djonsi shows symptoms of pain in her face and makes this notice to the nurses. She moans and cry’s a lot. Her heart rate is also high even is her blood pressure. Mrs. Djonsi is also sweating during some procedures.
Intended result SMART:
The patient will tell the nurses the pain is subsiding in the following week, this will appear from the VAS-score. (Carpenito)
Elaboration:
According to the centre of pain medicine , there are a number of criteria related to the determination of the nursing problem acute pain.
These criteria are:
- The pain suddenly occurred ( warning )
- The experience of the pain lasts less than six months
- The pain is treatable
- The source of the pain is easy to find (Máxima Medisch Centrum)
Because of the HIV Mrs. Djonsi has al lot of pain in different parts of her body. She feels and seems very uncomfortable. When the pain is treated she will feel better and be more rested.
Interventions:
Adjusting of the pain management with pain medication
Adjusting of the pain management with a VAS-score
Discuss the impact of pain
Evaluation:
After one week Mrs. Djonsi does not or nearly not show any sign of pain and says she feels comfortable and rested. The nurses will ask in every shift what the pain score is with the VAS- scale and it has to be below number 5. We will continue this procedure during her admission.
(Hesselink, 2010)
5.2 Inadequate therapy discipline
P: Mrs. Djonsi does not take her medication
E: Mrs. Djonsi’s husband tells her not to take her medicine
S: Mrs. Djonsi refuses to take the medicine and does not want to swallow and tries to spit the medicine out
Intended result SMART:
Mrs. Djonsi understands the need to follow the therapy and shows this in practice, Mrs. Djonsi will take the medicine in the following three days. (Carpenito)
Elaboration:
Because Mrs. Djonsi has al lot of pain it is urgent that she takes her medicine. She shows a lot of signs of pain of her face and body langue’s. If this pain is treaded she will feel comfortable and rested.
Interventions:
Promote self-confidence and self-reliance
Increase knowledge
Indicate witch factors new behaviour will influence
Tell and discuss the consequences with the patient and family
Evaluation:
After the intervention Mrs. Djonsi will show to the nurses that she takes her medicine. She will make notice to the nurses that she understands the need of taking her medication. Every week the nurses will evaluate how Mrs. Djonsi feels about taking the medication.
(Hesselink, 2010)
5.3 Swallowing disorder
P: Mrs. Djonsi is not able to feed herself properly
E: Mrs. Djonsi cannot swallow or chew easily
S: Mrs. Djonsi chokes often when eating and she lost weight during her admission. She also has not so much energy.
Intended result SMART:
Mrs. Djonsi take sufficient daily supply in balance with its activity level and metabolic rate within a day.
Elaboration:
Because of the fact that Mrs. Djonsi lost weight and is not able to eat properly is it of our concern that she takes her daily food. Mrs.Djonsi has to take therapy to improve her swallowing and eating this can take a lot of time. Because of this it is important to improve the situation quickly.
Interventions:
construction of a nasogastric tube
reduce the risk on aspiration
consult a speech therapist
Evaluation:
After two weeks Mrs.Djonsi gained weight and feels less weak. She will make this notice at the nurses. If the speech therapy is improving the nasogastric tube can be removed. (Carpenito)
5.4 Constipation
P: Mrs. Djonsi has almost no stool.
E: Mrs. Djonsi doesn’t have any body activity another cause is the stroke.
S: Mrs. Djonsi has a little bit of hard stool or no stool for the last 4 days. She also makes weird faces because her stomach hurts.
Intended result SMART:
The nurses will notice that Mrs. Djonsi has stool upcoming in the next two to three days and will report about this in her file.
Elaboration:
Because Mrs. Djonsi had a stroke she is not able to move herself or have any activity. Because of this her intestinal peristalsis changed. This is why Mrs. Djonsi has less stool. Due to the fact that Mrs. Djonsi is not able to feed herself properly and cannot eat much her stool also is less.
Interventions:
explain the importance of a balanced diet
Give laxative medication
Stimulate drinking enough water
Give health education
Evaluation:
After every day the nurses will report if Mrs. Djonsi had any stool . They will report about the colour and smell.
5.5 Social isolation
P: Mrs. Djonsi feels down and feels alone
E: Mrs. Djonsi had a stroke
S: Mrs. Djonsi cannot speak easily and is dejected. She says she feels alone and that she cannot do things anymore.
Intended result SMART:
Within a week Mrs. Djonsi says to feels better and feels less alone.
Elaboration:
Because Mrs. Djonsi had a stroke she is not able to speak good. She can hardly say a couple of words every time. With this small words she tries to make herself clear. Because people have a busy life here they have not the patients to wait for Mrs. Djonsi to finish her sentence. It frustrates her that she cannot speak because of this she feels alone and has no one to speak to.
Intervention:
Interact more with family members
Improve Mrs. Djonsi’s speech
Evaluation:
After every day the nurse will ask Mrs.Djonsi how she feels and if she feels less alone.
Description goals and interventions
Gaol: Pain
Intended result SMART:
The patient will tell the nurses the pain is subsiding in the following week, this will appear from the VAS-score. (Carpenito)
Goal: Inadequate therapy discipline
Intended result SMART:
Mrs. Djonsi understands the need to follow the therapy and shows this in practice, Mrs. Djonsi will take the medicine in the following three days. (Carpenito)
Goal: Swallow disorder
Intended result SMART:
Mrs. Djonsi take sufficient daily supply in balance with its activity level and metabolic rate within a day.
Goal: Constipation
Intended result SMART:
The nurses will notice that Mrs. Djonsi has stool upcoming in the next two to three days and will report about this in her file.
Goal: Social isolation
Intended result SMART:
Within a week Mrs. Djonsi says to feels better and feels less alone.
Five steps of EBP
The intervention that I have chosen is :
Increase knowledge
This intervention is from the second nursing diagnose inadequate therapy discipline. Because Mrs. Djonsi does not want to take her medicine because her husband says so. We hope that this intervention will make her take her medicine and that she will take her medication through increasing her knowledge.
Step 1: PICO- question
The clinical problem of the caretaker will be translated into a question.
Pico:
Problem: Inadequate therapy discipline
Intervention: Behavioral therapy
Co intervention: No behavioural therapy
Outcome: Adequate therapy discipline
Question: Can a woman of 48 years old with inadequate therapy discipline with behaviour therapy develop adequate therapy discipline ?
Elaboration:
With cognitive behaviour therapy we expect mrs. Djonsi to take her medicine. With this she will have adequate therapy discipline. If we threat mrs. Djonsi with cognitive behaviour therapy we expect her to take her medicine and reduce the pain. Because of the fact Mrs. Djonsi is against taking medicine we think it is best to involve him in the treatment for his wife. With behaviour therapy we want to improve Mrs. Djonsi’s behaviour and that she will take her medication.
ethical , legal and legislative aspects
To achieve the best results , it is important that account is held with various aspects . The aspects that must be taken into account its ethical , legal and legislative aspects . In Kenya there is almost no laws and regulations on the care that we use in the Netherlands . But it can still take into account the norms and values of the patient. Because Mrs. Djonsi depends on her husband and he believes in all what he says, it is important to take this into the therapies that mrs. Djonsi will use. By Mr.Djonsi’s involvement in the therapy’s mrs. Djonsi will also feel comfortable. This will make the therapy more effective and have come to the desired result .
Step 2: Find literature
To provide the best literature there are some criteria the literature has to meet
All queries contain the search term ' behaviour therapy' with a maximum of one additional search
The articles are not older than five years
Articles are chosen on the most reliable form of research, a systematic review has the highest reliability
The maximum number of items found in a search is ten
items found in a language that is readable : English or Dutch
Articles must be fully available
The content of the articles is about quality of student counselling and how it can be achieved
The found articles have to relate to the problem
Used google and Pubmed
Search term | Filters | hits | Useful articles |
Behaviour therapy AND pain AND reduce | Systematic review Five years | 8 | 1 |
Effectiveness of cognitive behaviour therapy | Five years | 6 | 1 |
Elaboration search tactics:
I wanted to find a article about the effect of cognitive behaviour therapy and the effect on pain and behaviour. Of the found articles I made a summery. The article is a randomised controlled trail, this means that the research contents a lot of other researches. To match different key words I was able to find the right literature
Step 3: review found literature
Summery article 1:
There has been a lot of research about cognitive behaviour therapy. The article I found shows the effectiveness about cognitive behaviour therapy. The article is an randomised controlled trail, this means it is an research of al lot of other researches. The research is done by a couple of different research departments. The study used 35 different researches to make their own study. The results show that cognitive behaviour therapy is effective on different parts of the cognition of the patient. CBT has effects on pain, disability, mood and catastrophising immediately post- treatment. The effect on mood did disappear at the follow up. This means that if we use CBT on mrs. Djonsi it could be effective and the outcome would be want we want it to be. The finding in the study is that CBT can be effective at patient with pain and it can be maintained for six months.
Summery article 2:
This study shows different results in different conditions . It is a large-scale study that are therapies to fit different syndromes . It is not specified in a specific disease. The results show that does not have the desired result in any disease. The research shows that the desired result can be the problems of mw.Djonsi , yet achieved it will take a lot of time. The investigation shows that CBT can be provided for a lot of different diseases and it is effective for people with signs of depression and pain.
Step 4: Applying found results
By applying the found scientific proof result will ms. improve Djonsi 's therapies . It is important to do so in small steps , by combining behavioural therapies , and a speech therapist , the best outcome will come forward. Because Ms. Djonsi problems speaking should here sould be given a lot of attention and patience. Due by involving her husband mw will give more attention to the therapies with his approval.
Step 5: Evaluation
Every week there will take an evaluation place with mrs.Djonsi and her family. The family needs to have a lot of patience with the therapies. It can take a couple of months to see any improvement. With the help of the nursing staff and doctors there is a good chance that mrs. Djonsi will improve.
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