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Medication Errors: Let’s Chat

15 Jun, 17 | by rheale

Gilberto Buzzi,

Guest Host of #ebnjc Twitter Chat on Wed., June 21 at 8pm UKM time

Senior Lecturer – Adult Nursing, School of Health and Social Care, London South Bank University, 103 Borough Road, London, SE1 0AA, t: +44 (0)20 7815 6739 | e: buzzig2@lsbu.ac.uk

Medication Errors

Ever experienced the terrors of been involved in a medication error, particularly one that had the potential to result in patient harm? If so, it is likely that you remember that moment quite vividly which may even have left you traumatized. These are some of the worse situations healthcare professionals may find themselves in as it goes against every core principle of their moral and professional duty. An entire section of The Code for Nurses and Midwives is dedicated to the preservation of patient and public safety and the importance of self-awareness to reduce potential harm associated to their practice (NMC, 2017), nonetheless, medication errors are still common.

In a review of medication error incidents reported to the National Reporting and Learning Systems (NRLS) over six years between 2005 to 2010 there were 525,186 incidents reported. Of these, 86,821 (16%) of medication incidents reported actual patient harm, 822 (0.9%) resulted in death or severe harm (Cousins et al 2012). A report commissioned by the Department of Health estimated the costs of preventable errors in the NHS, particularly relating to improper use of medication, to be around £770 millions a year, but most importantly, medication errors can cost lives.

“Medication errors occur when weak medication systems and/or human factors such as fatigue, poor environmental conditions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death” (WHO, 2017). This suggests that medication errors could be preventable at different levels. Whilst there is robust legislation and guidelines to ensure patient safety particularly in relation to the administration of medicine, following simple and practical steps such as the 10 rights of Medication Administration can greatly reduce the risk of errors and literally save lives. These are:

  1. Right patient: Ask patient to identify themselves and check the name on the prescription and wristband. Ideally, use 2 or more identifiers.
  2. Right medication: Check the name of the medication and the expiry date with the prescription. Make sure medications, especially antibiotics, are reviewed regularly.
  3. Right dose: Check appropriateness of the dose using the BNF or local guidelines. If necessary, calculate the dose and have another nurse calculate the dose as well.
  4. Right route: Again, check the order and appropriateness of the route prescribed.
  5. Right time: Check the frequency of the prescribed medication. Confirm when the last dose was given.
  6. Right patient education: Check if the patient understands what the medication is for and who to contact in case of side-effects.
  7. Right documentation: Ensure you have signed for the medication AFTER it has been administered. Ensure the medication is prescribed correctly.
  8. Right to refuse: Ensure you have the patient consent to administer medications.
  9. Right assessment: Check your patient actually needs the medication. Check for contraindications. Baseline observations if required.
  10. Right evaluation: Ensure the medication is working the way it should and reviewed regularly. Ongoing observations if required.

Points 1 to 5 refer to NMC standards for medicine management. Points 6-10 are additional checks that have been adopted by multiple US nursing boards and research panels to enhance patient safety.

References:

Cousins, D.H., Gerrett, D. and Warner, B. (2012) A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010). British Journal of Clinical Pharmacology, 74(4): pp. 597–604

Frontier Economics (2014) Exploring the costs of unsafe care in the NHS. [online] London, pp.1-21. Available at: http://www.frontier-economics.com/documents/2014/10/exploring-the-costs-of-unsafe-care-in-the-nhs-frontier-report-2-2-2-2.pdf [Accessed 10 Jun. 2017].

Nmc.org.uk. (2017). Read The Code online. [online] Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ [Accessed 10 Jun. 2017].

World Health Organization. (2017). Medication Without Harm: WHO’s Third Global Patient Safety Challenge. [online] Available at: http://www.who.int/patientsafety/medication-safety/en/ [Accessed 10 Jun. 2017].

Standards for medicine management: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-medicines-management.pdf

Report a problem with a medicine or a medical device: https://yellowcard.mhra.gov.uk/https://yellowcard.mhra.gov.uk/

Medicines & Healthcare products Regulatory Agency: https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency

Interesting read: https://www.zebra.com/content/dam/zebra_new_ia/language-assets/en_gb/solutions_verticals/Verticals_Solutions/healthcare/guide/mobile-printing-solutions-guide-en-gb-emea.pdf

https://www.england.nhs.uk/wp-content/uploads/2014/03/psa-sup-info-med-error.pdf

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=68464&type=full

http://www.pharmaceutical-journal.com/news-and-analysis/medication-errors-cost-the-nhs-up-to-25bn-a-year/20066893.article

 

 

Beyond the Sleeping Pill: Cognitive Behavioral Therapy for Insomnia

11 Jun, 17 | by rheale

Contributed by Roberta Heale, Associate Editor EBN, @robertaheale, @EBNursingBMJ

There’s not a more frustrating than tossing and turning all night.  However, between 30-50% of adults identify ongoing sleep disturbances.  While restless sleep once in a while is a nuisance, insomnia is a different story. It can be a significant problem particularly with older adults who are at higher risk of depression, falls, stroke, decline in cognitive and overall functioning.  The risks are exacerbated when mixed with sleeping pills which, themselves, increase the risk of falls, fractures and mortality. 1

So what is there to offer a patient other than medication?  Turns out, a lot.  One treatment is showing great promise, Cognitive Behavioural Therapy-Insomnia, or CBT-I.  Using the same exploration of the interactions between thoughts, emotions and behaviours, the focus is on sleep.  Sleep patterns, sleep hygiene, anxieties and thoughts that run through a patient’s mind at night are addressed.  CBT-I requires a commitment from the patient to make changes to their routines and practice the techniques that are offered, however, the outcomes can be very good.

One study, reviewed in a commentary in the EBN journal, identifies the usefulness of CBT-I.  Check out: Cognitive–behavioural therapy for insomnia is effective, safe and highly deployable http://ebn.bmj.com/content/early/2017/04/12/eb-2016-102523  Encouragingly, although training is required to deliver CBT-I, but one does not need to be a healthcare professional to provide CBT-I therapy, which adds to the potential of this treatment.

Sleep permeates every part of our lives.  With so many adults struggling with insomnia, CBT-I is an encouraging, positive, non-pharmacological option.

1. Alessi  C, Martin  JL, Fiorentino  L, et al. Cognitive behavioral therapy for insomnia in older veterans using nonclinician sleep coaches: randomized controlled trial. J Am Geriatr Soc 2016;64:1830–8.

 

Pain in children with cancer: myths, management, and the family context

4 Jun, 17 | by atwycross

This week’s EBN Twitter Chat on Wednesday 7th June 2017 between 8-9 pm (UK time) will focus on pain in children with cancer and is being hosted by Roses Parker (parker11@lsbu.ac.uk), PhD student in Children’s Nursing, London South Bank University @Roses_Parker and Perri Tutelman (ptutelman@dal.ca), PhD student in Clinical Psychology, Dalhousie University Twitter @PerriTutelman.

Participating in the chat requires a Twitter account. If you do not have one you can create an account at www.twitter.com. Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc. You can contribute by sending a tweet (tweets are text messages limited to 140 characters) and adding #ebnjc (the EBN Twitter chat hash tag) to your tweet.

Each year, over 300,000 children are diagnosed with cancer worldwide (Steliarova-Foucher, 2017). With an increasing amount of research on pediatric cancer, greater consideration is now being given to the symptoms and side effects associated with the disease, in addition to the cancer itself. Pain is one of the most common and burdensome symptoms of pediatric cancer according to both children and their parents (Miller, Jacob & Hockenberry, 2011; Poder, Ljungman & Essen, 2010). Evidence suggests pain affects children with cancer regardless of their age, gender or diagnosis and continues throughout the cancer journey (Twycross et al., 2015). Children with cancer experience pain from three main sources. Firstly, cancer itself causes pain when tumour affects bones or soft tissue (Oakes, 2011). Secondly, children with cancer undergo many painful procedures such as lumbar punctures, bone marrow aspirates and surgery (Cline et al., 2006; Walco et al., 2005). Finally, increasingly aggressive treatments, such as chemotherapy and radiotherapy, have painful side-effects such as mucositis, peripheral neuropathy, and burns (World Health Organisation, 2012). Evidence suggests pain affects children with cancer regardless of their age, gender or diagnosis throughout the cancer journey (Twycross et al., 2015), and can have a significant impact on the lives of children and their families. Unfortunately, while various pain management strategies exist to manage children’s cancer-related pain (e.g. medications, psychological and physical pain management techniques), pain continues to be a problem for the majority of children with cancer.

more…

Supporting newly qualified nurses into the world of work

30 May, 17 | by dibarrett

Jane Wray, Senior Research Fellow, Director of Research, School of Health and Social Work, University of Hull

Finishing university and starting employment is an exciting time for newly qualified nurses. It’s the beginning of what is generally a long, successful and exciting career within the profession. It can, however, also be a stressful or challenging time as they make the transition from student nurse to registered, fully autonomous practitioner. Newly qualified nurses can feel that they are unprepared for their new role and the demands made upon them (Feng and Tsai, 2012); this can lead to stress and dissatisfaction (Edwards et al. 2015), and some decide to leave the profession within a year of qualifying. This results in significant personal costs for individual nurses and has an impact upon employers, organisations and patients.

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International Council of Nurses Congress – Using Social Media to Engage with Nurses

21 May, 17 | by josmith

Roberta Heale (@robertaheale) & Joanna Smith (@josmith175) Associate Editors, EBN

We are presenting how Evidence Based Nursing (EBN) is using social media to engage with nurses at the International Council of Nurses (ICN) Congress, being help at the end of May 2017 in Barcelona, Spain. Nurses across the globe will be exploring nurses’ roles in leading the transformation of care, & is an opportunity for nurses to build networks, share & disseminate nursing practices across specialties, cultures & countries, http://www.icnbarcelona2017.com/

The ICN ams to

Demonstrate & advance the nursing contribution to informed & sustainable health policies;

Support nursing’s contribution to evidence-based healthcare & encourage problem-solving approaches to health priority needs:

Provide opportunities for an in-depth exchange of experience & expertise within & beyond the international nursing community.

We are excited to be representing the work of EBN at the ICN Congress, and networking with peers. Although the journal’s main purpose is to publish expert commentaries on current research that is relevant to nursing, over the last few years EBN editors have implemented a social media strategy to increase engagement with our readers, their access to evidence for practice & awareness of important health issues. We will be sharing our social media strategies that include:

  • Posting regularly on our Facebook @BMJNursing & Twitter account @EBNursingBMJ;
  • Hosting fortnightly Twitter Chats which are linked to a new Opinions article series relating to discussing participants’ key messages during the Twitter chat;
  • Publishing weekly blogs (http://blogs.bmj.com/ebn/);
  • Recording podcasts with authors of commentaries to expand & debate in more depth issues raised in the commentary.

Caring for agitated patients

14 May, 17 | by josmith

This week’s EBN Twitter Chat on Wednesday 17th May 2017 between 8-9 pm (UK time) will focus on caring for agitated patients and is being hosted by Angela Teece (A.M.Teece@leeds.ac.uk), Trainee Lecturer in
Adult Nursing, University of Leeds @AngelaTeece and Sam Freeman (samantha.freeman@manchester.ac.uk) Lecturer in Adult Nursing, University of Manchester Twitter @Sam_Freeman.

Participating in the Twitter chat requires a Twitter account; if you do not have one you can create an account at www.twitter.com. Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to adding #ebnjc (the EBN Twitter chat hash tag) to your tweet, this allows everyone taking part to view your tweets.

What is an agitated patient? It could be a patient who is restless, kicking their legs over the bed rails or refusing to lie still. Or maybe it is the patient who repeatedly flicks off the saturation probe, causing the machine to alarm. Or do you see an agitated patient as one whose behaviour risks serious harm to themselves or you as their nurse? The underlying causes for admission to critical care areas is vast. The commonality is the individual is experiencing illness so severe they cannot be managed elsewhere and require drastic intervention. The admission can be traumatic and potentially life altering event. Delirium, which is common amongst intensive care (ICU) patients, can present as extreme agitation, and lead to poor compliance with essential therapies and rehabilitation (Collinsworth et al., 2016). Awakening from sedation or withdrawal from alcohol and drugs may also lead to agitated behaviour.

Management of agitation is dependent upon the severity of the problem and the clinical area where the patient is being nursed. A restless patient might require extra supervision, particularly at night when staffing and patient visibility is poor. Such patients benefit from regular reorientation. In ICU, agitated patients are at risk of removing essential devices, such as central venous catheters, potentially causing serious harm or death (Mion, 2008). In more severe cases of agitation the management approach may be either sedation (chemical) or physical restraint, such as cuffs or ‘boxing gloves’. Management of agitated patients presents many issues for nurses in terms of staff morale, resource management and patient safety. Nurses might be concerned about the ethical issues underpinning the use of restraint. A recent court case highlighted that sedation cannot be classed as a deprivation of liberty to critical care patients as they physical illness is restricting their freedom, rather than any sanctions imposes by the hospital. Howver the use and role of physical restraint in management of agitation in critical care was not clarified.

Freeman et al. (2015) sought the opinions of nurses in relation to the use of physical restraint and  found some nurses expressed discomfort about the use of physical restraint and needed more education and support regarding physical restraint use. The authors of this blog are currently involved in further research in this area and would welcome your responses and opinions in this week’s Twitter chat., which will focus on:

  • How do you feel about caring for agitated patients?
  • Have you experienced problems with patient agitation where you work?
  • Do you receive help when managing agitated patients?
  • Do you use restraint?

https://medhealth.leeds.ac.uk/profile/1100/1715/angela_teece

https://www.research.manchester.ac.uk/portal/Samantha.Freeman.html

COLLINSWORTH, A. W., PRIEST, E. L., CAMPBELL, C. R., VASILEVSKIS, E. E. & MASICA, A. L. 2016. A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. J Intensive Care Med, 31, 127-41.

FREEMAN, S., HALLETT, C. & MCHUGH, G. 2015. Physical restraint: experiences, attitudes and opinions of adult intensive care unit nurses. Nurs Crit Care, 21, 78-87.

MION, L. C. 2008. Physical Restraint in Critical Care Settings: Will They Go Away? Geriatric Nursing, 29, 421-423.

Music therapy in improving the quality of life of palliative care patients: does it work?

8 May, 17 | by hnoble

Dr Joanne Reid, Reader in Cancer Nursing, School of Nursing and Midwifery, Queens University Belfast.

Research Collaboration in Northern Ireland between Queen’s University, ‘Every Day Harmony’ and Marie Curie Hospice Belfast, funded by the Public Health Agency, Northern Ireland.

Despite recent advances in medicine, patients with advanced illness continue to report high rates of suffering due to psychoexistential concerns such as loss of function, meaninglessness and anxieties in relation to death and dying. Palliative care recognises the ‘total pain’ experienced by end-of-life patients and supports the use of adjunct complementary therapies to address aspects of patient suffering still outside the remit of medical science and technology.

Music therapy is frequently used as a palliative therapy and entails the use of music to achieve individual goals in the context of a therapeutic relationship with a professional music therapist. Aligning with the goals of palliative care, the primary aim of music therapy is to improve people’s quality of life by relieving physical and psychological symptoms, facilitating communication and alleviating spiritual or existential concerns.

However, there are currently no guidelines in place for the use of music therapy in palliative care. This highlights the need for a stronger evidence base that demonstrates both the benefits and risks to help inform future music therapy provision. To date, primarily because of a lack of robust research, the evidence for music therapy’s effectiveness on patient reported outcomes is positive but weak. Music therapy is an allied health profession and can help a wide range of people affected by illness and disability. It uses musical interaction, and creativity through music, to address a patient’s clinical needs – whether they are psychological, physical, emotional, cognitive or social.

The core of music therapy is the relationship between the music therapist and the client. The client can either actively play instruments alone or with the music therapist, sing, or listen as they play. If the patient’s family is present, they may also be involved in the music therapy session. Patients can play to music already known to them, or play spontaneously and the therapist uses their musical skills to support them in this form of expression. Music therapy can also involve legacy work where the music therapist supports the patient to write a song for their family. In music therapy, our musical tastes and song choices can reveal the ‘person’ behind the terminal illness, helping patients reminisce about happier times, have fun in the moment, and leave a legacy for the future. As Shakespeare simply put it “When words fail, music speaks”

We are currently managing a study which is open for recruitment and running at Marie Curie Hospice Belfast with Music therapy provided by the Belfast based company Ever Day Harmony. A full study protocol is published elsewhere (DOI: 10.1186/s40814-016-0111-x ). The aim of the study is to determine the benefits of music therapy to people at the end of their lives. Fifty-two patients at the hospice are taking part. Half will receive six music therapy sessions over three weeks, as well as standard palliative care. The other half will receive standard palliative care (although they will also be offered up to two sessions of music therapy once the research period has finished). We will also collect data from HCPs and carers to understand their views on the impact of music therapy for patients. This is a feasibility study, with a view to undertaking a larger multi-site trial across the UK to evaluate the effectiveness of music therapy in improving the quality of life of palliative care patients.

Everyone has their own unique taste in music. It’s part of who we are. There’s been such a wide range of suggestions in the hospice so far: from classical music, such as Chopin, to traditional Irish music, to pop music. The music therapist delivering the intervention made a recent comment: I’ve learned so much from my clients. Everyone has so much to give, right up until the end, and it’s a privilege to be able to work with them at such an important time.”

 

Do we need to rethink how we educate healthcare professionals about pain management?

30 Apr, 17 | by atwycross

Do we need to rethink how we educate healthcare professionals about pain management?

This week’s EBN Twitter Chat on Wednesday 3rd May between 8-9 pm (UK time) is taking place live from the British Pain Society’s (@BritishPainSoc) Annual Scientific Meeting in Birmingham. The chat will focus on whether we need to rethink how we educate healthcare professionals about pain management. The Twitter Chat will be hosted by Dr Ameila Swift (@nurseswift) and Professor Alison Twycross (@alitwy). This Blog provides some context for the Chat.

Participating in the Twitter Chat

Participating in the chat requires a Twitter account; if you do not have one you can create an account at www.twitter.com. You can contribute to the chat by sending tweets with #ebnjc included within them.

Current approach to pain education

The International Association for the Study of Pain (IASP) have published curricula for pre-registration training for healthcare professionals (see: http://www.iasp-pain.org/Education/CurriculaList.aspx?navItemNumber=647). These consist of lists of topics specifying the knowledge students need to obtain about pain management during pre-registration courses. This reflects the traditional approach to curriculum design where learning outcomes focus on theoretical knowledge and pay little attention to application in practice. Indeed, research in this area has tended to focus on knowledge and curricula deficits (Briggs et al. 2011, Twycross & Roderique 2013). As patients of all ages continue to experience unnecessary unrelieved pain (Twycross & Finley 2013; Meissner et al. 2015) there is a need to explore ways of ensuring knowledge is used in practice. This is timely because the International Association for the Study of Pain (IASP) has named 2018 the Global Year for Excellence in Pain Education (see: http://www.iasp-pain.org/GlobalYear).

Is part of the problem the way we evaluate the education provided?A literature review of research into pain education, conducted for this blog, suggests the impact of educational interventions does not look beyond three months with most studies only assessing pre- and post-intervention knowledge gain. Students and junior staff feel powerless and might ‘shy away from their incompetence’ in treating patients when management is not straightforward (Tellier et al. 2013), demonstrating the gap between increased knowledge and increased competence.

more…

Seeing the Wood and the Trees: Using Construal Level Theory to see what Proxy Decision Makers are thinking about

23 Apr, 17 | by josmith

Helen Convey. Lecturer in Adult Nursing, School of Healthcare, University of Leeds

Individuals who are living with dementia and who lack decision making capacity require proxy decision makers to make decisions for them. Individuals may express their interests and desires through behaviour and verbal communication, however, memory loss results in a lack of psychological continuity between the past and the present self. When there is a conflict between the individual’s past values and interests and their present values and interests proxy decision makers encounter an ethical dilemma. The aim of this feasibility study was to explore the potential use of Construal Level Theory (CLT) as a way of analysing the thinking of proxy decision makers where this conflict occurs.

CLT (Liberman and Trope, 2014; Trope and Liberman, 2010) contends that people use mental construal to traverse psychological distance and to think about choices, alternatives and perspectives in different dimensions; temporal, spatial, social and hypothetical. In mental construal abstraction is used to move beyond direct, real experiences of the self, across psychological distance, to form a subjective view of an object or action. High-level construal is more abstract, central values receive attention. Low-level construal is concrete, detailed and contextualised.

Participants were given a scenario in one to one semi-structured interviews. They read the scenario and were asked what they were thinking and feeling. Thematic analysis was used to discover patterns of decision making. Participant responses within the themes were then analysed for abstractness of language using the Linguistic Category Model (Semin and Fiedler, 1991). Participants were found to travel across psychological distance to think abstractly about the person in the scenario. They used mostly abstract thinking to establish central values and beliefs and mostly concrete thinking to express pragmatic concerns. We concluded that CLT can be used to analyse the thinking of proxy decision makers.


References:

Liberman, N. and Trope, Y. 2014. Traversing psychological distance. Trends in Cognitive Sciences. 18(7), pp.364-369.

Semin, G.R. and Fielder, K. 1991. The Linguistic Category Model, its Bases, Applications and Range. European Review of Social Psychology. 2(1), pp.1-30.

Trope, Y. and Liberman, N. 2010. Construal-Level Theory of Psychological Distance. Psychological review. 117(2), pp.440-463.

 

 

Treating pain during pregnancy and breast feeding

16 Apr, 17 | by josmith

This week’s EBN Twitter Chat on Weds 19th April at 8-9pm UK time will focus on pain during pregnancy, how important and difficult is to treat pain during pregnancy and breast feeding.

The Twitter Chat will be hosted by Dr Massimo Allegri, Assistant Professor in Anesthesia Intensive Care and Pain Medicine at the University of Parma (Italy),@allegri_massimo. Participating in the Twitter chat requires a Twitter account; if you do not already have one you can create an account at www.twitter.com. Once you have an account contributing is straightforward, You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

The Pain Department of University Hospital of Parma is one of the biggest pain clinic in Italy and it is the most important research centre about acute ad chronic pain in Italy and one of the most important in Europe.

Furthermore, next year a new PhD Position in Pain will be settled up together with Alborg University and Prof Lars Arendt Nielsen about chronic pain and central sensitization. Furthermore, University of Parma organizes one of the most important translational pain meeting in the world: SIMPAR (www.simpar-pain.com).

Pain affects 20% of adult population worsening not only quality of life, but also outcome of patients who refer it. Unfortunately, pain continues to being undertreated and under-recognized. Chronic pain is not just a symptom but it is a real disease that needs an accurate diagnosis and appropriate therapy against the pain generator pathophysiology.

This problem is even more important during pregnancy and breastfeeding. The fear to give drugs that can hurt foetus/neonate can drive the physician to a “wait and see” approach that cannot solve the problem to the mother. Furthermore, during pregnancy there are several physiological changes that can worsen previous pain or generate new one. Finally, all the drugs are obviously off label and it is difficult to know exactly their real toxicity.

On Wednesday 19th April during the twitter chat we will continue the conversation to consider how to drive the therapy for patients during pregnancy and breastfeeding. We will discuss all together which multidisciplinary approach could be useful and how important is to diagnose the right pathophysiological mechanism that triggers the acute or chronic pain:

  • Which are the classifications of the drugs that could drive clinicians to use the drugs to alleviate pain?
  • When is more harmful to use some specific drugs?
  • Which concerns do we have to consider when we give a drug to a breastfeeding mother?
  • How to perform the right pathophysiological diagnosis?
  • Do we have to stop some drugs if the women would like to become pregnant

Please join us to discuss this important medical, nursing and public health challenge.

References

1 Coluzzi F, Valensise H, Sacco M, Allegri M Chronic pain management in pregnancy and lactation. Minerva Anestesiol. 2014 Feb;80(2):211-24.

2  Narayan B, Nelson-Piercy C. Medical problems in pregnancy. Clin Med (Lond). 2016 Dec;16(Suppl 6):s110-s116.

3 Tepper D. Pregnancy and lactation–migraine management. Headache. 2015 Apr;55(4):607-8.

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