Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington


The majority of people, including mental health professionals, consider a person to be mentally healthy as long as there is an absence of psychopathology, but there is more to mental health than this assumption. Not all people are alike. People differ in term of their values, attributes, emotional reactions and intelligence. As long as these differences do not affect the person's ability to live happily, make harmonious personal and social relationships and work efficiently, the person is considered healthy and normal. There cannot be just a single definition of mental health that fits all. However, there are some traits that mentally healthy people share and these contribute to a happy life.

            A mentally healthy person exhibits the ability to think clearly and realistically. He is creative and positive. He can reason logically, use good judgement and reach insightful conclusions. The person also shows good problem-solving capacity.

              The person has good control over his behavior and takes responsibility for his actions. His behavior and actions reflects an accurate appraisal of reality. He also engages in constructive activities.

Interpersonal Relationships
                                       A mentally healthy person has the ability to form and sustain close, loving and adaptive relationships. He is not too demanding and has the ability to feel emphatically for others. The person is able to work amicably with others. He can also manage interpersonal conflicts constructively.

                 The person is able to negotiate each developmental stage successfully and maintain a healthy self-esteem. There is a realistic sense of self-worth. The person is able to attain and maintain a self-defined spirituality. During the times of stress and conflict, doubts do not erode this self-esteem, rather it helps to deal with the stress.

            A healthy person is happy most of the time and has the ability to enjoy life. He does not carry undue fear, guilt and anxiety and has the ability to love and to be loved. He can also deal with conflicting emotions without much stress.
         Mental health and illness can be conceptualized as a continuum with ideal mental health on one end and severe mental illnesses on the other end with shades of both in between.

 Nursing Path


Unfortunately, there are many myths and misconceptions shrouding the mental illnesses that have led to unnecessary fear, ignorance and stigmatization. Below are some of the common myths and misconceptions:
  1. Various religious - spiritual factors are considered  as the cause of mental illnesses. Many such beliefs include the non-appeasement of gods; deities or spirits; the role of black magic and evil forces; possession by evil spirits, and sins of previous lives.
  2. Mental illnesses are considered to be the result of excessive masturbation, loss of semen and sexual intercourse with a menstruating woman.
  3. Mental illness in a pregnant mother can be transmitted to the unborn baby.
  4. Mental illness can be contracted by touching, eating and living with a patient with a mental illness.
  5. All mentally ill patients are violent and dangerous. Therefore, they should be locked up either in jails or mental asylums.
  6. Mental illness is an incurable lifelong illness.
  7. Medications used for the treatment of mental illnesses can change the personality of the person. Also, the person becomes addicted to these drugs and may need to take the medication throughout his life.
  8. Mental illnesses can be cured easily through prayers, offerings and exorcism. Priests and shamans are considered to be authorities in the treatment of patients with mental illness.

 Nursing Path


In order to share or report the research findings, researcher has to follow some criteria, which are as follows:

1. Selecting proper channel for communicating: The researcher has to select suitable and appropriate channel to disseminate his or her research findings, such as student-related outlets are these and dissertation; however, professional academicians generally need publication of research articles in professional journals, books, or oral research presentations in conference through papers or slides.

2. Knowing the consumers: Researchers must know in advance to whom they want to communicate their research findings, such as nursing research findings to clinical bedside nurses, nurse educators, nurse administrators, health care professionals, or even the general public. This will help in choosing the right method, mode, and content of research to be communicated.

3. Developing an effective plan for writing a research report: A plan for writing a research includes the following aspects:

  • Decide on authorship: Researchers have to decide among themselves as to who will be the leading author and the contributing authors. The International Committee of Medical Journal Editor (ICMJE) advice that authorship credits should be given only to those who have made a substantial contribution to the conceptual designs of the study, data analysis and interpretations, drafting or revising the manuscript, and approving the final version of the manuscript.
  • Deciding about the content: Researchers also have to decide how many papers are required to communicate the findings of the research effectively, as sometimes researchers collect a huge amount of data that cannot be communicated in a single paper.
  • Preparing outline of report: It is important that if there are multiple authors of a report, each one has responsibility for different sections of manuscript. The advantages of having an outline is that it can be incorporated into a timeline that sets goals for completing the manuscript.
  • Assemble the material needed to begin a draft and finally start preparing a report with outlined timeline.
4. Careful selection of a journal for publication of a report: In selecting a journal for publication, some important factors must be kept in mind such as the journal's goal, audience, its prestige, acceptance, and frequency of publication.

5. Careful review of the author's manuscript guidelines: Researchers need to be careful to review the journal instructions to authors because each journal has its own guidelines for submission of the manuscript. Most of the journals limit the manuscript to 15-20 double-spaced typed pages.

 Nursing Path



Complete and appropriate answer of a research question largely depends on the selection of appropriate methods of data collection, which generally begin at the time of selection of a research design. A research question or hypothesis may be answered by using one or more number of methods of data collection. However, selection of appropriate method of data collection is  influenced by several factors as discussed below:

  • The Nature of phenomenon under study: The nature of the phenomenon under study largely influences the choice of the method of the data collection. Each research phenomenon has its particular characteristics and, therefore, needs different approaches and methods of data collection. For example, some of the phenomenon  only can be studied appropriately through observation such as clinical practices or processes in particular nursing procedures. Similarly, knowledge of a group of nurses only can be assessed through questioning or interviews. Therefore, the nature of the phenomenon under study significantly affects the selection of particular method of data collection.
  • Type of research subjects: Data collection methods are also influenced by the type of subjects under study. For example, data  collection from physically or psychologically disabled subjects can be done either by interview or through observation, where data collection through questionnaire is not feasible. On the other hand, if data has to be collected from objects or institutions, questionnaires or interviews may not be possible at all, and researchers will have to depend mostly on observation to collect relevant data.
  • The type of research study: Quantitative and qualitative research studies need different methods of data collection. For examples, in qualitative research, more in-depth information is required, therefore, focused group interviews or unstructured participatory interviews are feasible for data collection, while for quantitative research studies more structured interviews, questioning, or observation is used for data collection.
  • The purpose of the research study: The purpose of the study also influences the choice of the methods of data collection, such as in a study conducted with the purpose of the exploration of phenomenon, in-depth interviews may be needed for data collection, while studies conducted with purpose of description or correlation of study variables may need more structured methods of data collection.
  • Size of the study sample: When a study is conducted on a small sample, interviews or direct observation may be possible, while these methods can be tedious for large samples. For larger samples, questionnaires can be better and more referable methods for data collection. Interviews and observation methods will also be cost-effective and easy for smaller groups, while questionnaires will be convenient, easier and cost-effective methods of data collection for larger samples.
  • Distribution of the target population: If target population is spread in a large geographical area, it will not be possible to carry out interviews or observation, and therefore, mailed questionnaires may be a better option, which will be more convenient and cost-effective in such conditions.
  • Time frame of the study: If a research is conducted for the long time, it may permit the researcher to use the less-structured methods of data collection to gain in-depth information, while short time-frame studies may not allow the researcher to use the unstructured methods of data collection, where he or she gets very little time for data collection and analysis. Therefore, structured methods of data collection are used more short-term research designs.
  • Literacy level of the subjects: Illiterate subjects put constrains on the use of self-responding methods of data collection such as questionnaires. for illiterate subjects, interviews conducted in native language is one of the few possible methods of data collection used, while more varied and numerous options in methods of data collection are available for literate subjects.
  • Availability of resources and manpower: Some of the method of data collection require more quantities of resources and manpower, such as conducting interviews and observation compared to the use of questionnaires. Therefore, availability of resources and manpower also affects the selection of methods of data collection.
  • Researcher's knowledge level and competence: The researcher's knowledge and competence also affects the selection of methods of data collection, for example conducting an interview observation may require special social and psychological knowledge, skills, and competence, while the use of questionnaires may not demand these skills, however for the development and construction of a good questionnaire, good writing skills may be required.
Criteria of evaluation/assessment of data collection methods
The appropriateness of the data collection method may be evaluated or assessed by using following criteria:

  1. Accuracy and completeness of data collection: Researcher must ensure that data collection methods used will yield accurate and complete data to answer research questions or test hypothesis.
  2. Compatibility with educational level, sociocultural values, and beliefs of the subjects.
  3. Cost-effectiveness of and speed in data collection procedure.
  4. In accordance with nature of phenomenon, type, purpose, time frame, and resources available for the study.
  5. Further, following criteria may considered while evaluating or assessing the method of data collection:
  • Is data collection method complete in all the aspects of study and study variables.
  • Are data collection methods thoroughly described?
  • Are data collection methods in accordance to research questions/hypothesis to be tested?
  • Are validity and reliability of data collection methods established?
  • Are the number of methods used for data collection sufficient for complete coverage of research data or additional methods required for data collection?
  • Are anonymity and confidentiality assured?
  • Are instruments described in detail?
  • Where the criterion measures or scoring methods clearly established?



  • Refers to formation of calculi (e.g. gallstones) in the gallbladder.

  • Is acute or chronic inflammation of the gallbladder.
    • Acute cholecystits – may be calculous (with gallstones) or acalculous (with gallstones).
    • Chronic cholecystitis – may follow acute cholecystitis, although it often occurs independently. It is usually associated with gallstone formation.
Risk Factors
Results from changes in bile components or bile stasis, associated with:
  • Infection
  • Cirrhosis
  • Pancreatitis
  • Celiac disease
  • Diabetes mellitus
  • Pregnancy
  • Hormonal contraceptive use
  • Obstruction of the cystic duct by an impacted gallstone
  • Tissue damage due to trauma, massive burns, or surgery
  • Gram-negative septicemia
  • Multiple blood transfusion
  • Prolonged fasting
  • Hypertension
  • Overuse of opioid analgesics
Calculi usually from solid constituents of bile; the three major types are:
  • Cholesterol gallstones – the most common type, thought to form in supersaturated bile
  • Pigment gallstones – formed mainly of unconjugated pigments in bile precipitate
  • Mixed types – with characteristics of pigment and cholesterol stones.
Gallstones can obstruct the cystic duct, causing cholecystitsi, or the common bile duct, which is called choledocholithiasis.
  • In acute and chronic cholecystitis, inflammation causes the gallbladder wall to become thickened and edematous and causes the cystic lumen to increase in diameter.
  • If inflammation spreads to the common bile duct, obstruction of bile drainage can lead to jaundice. Other possible complications include: (Empyema i.e. pus-filled gallbladder, perforation, emphysematous cholecystitis)
Assessment/Clinical Manifestations/Signs And Symptoms
Cholelithiasis (up to ½ of persons with gallstones are asymptomatic; however possible clinical manifestations include the following)
  • Episodic (commonly after a high-fat meal), cramping pain in the right upper abdominal quadrant or the epigastrium, possibly radiating to the back near the right scapular tip (i.e. biliary colic)
  • Nausea and vomiting
  • Fat intolerance
  • Fever and leukocystosis
  • Signs and symptoms of jaundice
Acute Cholecystitis
  • Biliary colic
  • Tenderness and rigidity in the right upper quadrant elicited on palpation (i.e. Murphy’s sign)
  • Fever
  • Nausea and vomiting
  • Fat intolerance
  • Signs and symptoms of jaundice
Chronic Cholecystitis
  • Pain, which is less severe than in the acute form
  • Fever, which is less severe than in the acute form
  • Fat intolerance
  • Heartburn
  • Flatulence
Laboratory and diagnostic study findings
  • Biliary ultrasonography (i.e. cholecystosonography) can detect gallstones in most cases.
  • White blood cell count reveals leukocytosis
  • Serum alkaline phosphatase is elevated
  • Ultrasonography detects gallstone
  • Endoscopic retrograde cholangiopancreatography may reveal inflamed common bile ducts, gallbladder, and gallstones.
  • Percutaneous transheptic cholangiography can identify gallstones within the bile ducts.
Medical Management
Teach the client about planned treatments.
  • Chenodeoxycholic acid is administered to dissolve gallstones. It is effective in dissolving about 60% of radiolucent gallstones. Pigment gallstones cannot be dissolves and must be excised.
  • Nonsurgical removal, such as lithotripsy or extracorpeal shock wave therapy, may be implemented.
Surgical treatment may be ordered.
Laparoscopic cholecytectomy (usually outpatient surgery) is performed through a small incision made through the abdominal wall in the umbilicus.
  • Assess incision sites for infection. Instruct the client to notify the health care provider if loss of appetite, vomiting, pain, abdominal distention, or fever occur.
  • Advise the client that he will need assistance at home for 2 to 3 days.
Cholecystectomy is removal of the gallbladder after ligation of the cystic duct and artery. Inform the client that a T-tube will be inserted to drain blood; serosanguineous fluids, and bile and that the T-tube must be taped below the incision
Choledochostomy is an incision into the common bile duct for calculi removal.
Cholecystomy is the surgical opening of the gallbladder for removal of stones, bile, or pus, after which a drainage tube is placed.
Nursing Diagnosis
  • Acute pain secondary to biliary obstruction
  • Ineffective coping related to nausea
  • Deficient knowledge related to diagnosis
  • Impaired gas exchange related to high abdominal surgical incision.
  • Impaired skin integrity related to altered biliary drainage after surgical incision.
  • Imbalanced nutrition related to inadequate bile secretion.
Nursing Management
Provide nursing interventions during an acute gallbladder attack.
  • Intervene to relive pain; give prescribed analgesics
  • Promote adequate rest
  • Administer IV fluids, monitor intake and output
  • Monitor nasogastric tube and suctioning
  • Administer antibiotics if prescribed.
Provide adequate nutrition.
  • Assess nutritional status. Encourage a high-protein, high-carbohydrate, low-fat diet.

Nursing Care Plan
1.   Nursing Diagnosis
  • Fluid Volume, risk for deficient
Risk factors may include
  • Excessive losses through gastric suction; vomiting, distension, and gastric hyper­motility
  • Medically restricted intake
  • Altered clotting process
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, absence of vomiting.
Nursing Interventions
  • Maintain accurate record of I&O, noting output less than intake, increased urine specific gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill.
    • Rationale: To provide information about fluid status and circulating volume needing replacement.
  • Monitor for signs and symptoms of increased or continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, depressed respirations.
    • Rationale: Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.
·        Eliminate noxious sights or smells from environment.
·        Rationale: Reduces stimulation of vomiting center.
·        Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.
·        Rationale: Decreases dryness of oral mucous membranes; reduces risk of oral bleeding.
·        Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture.
·        Rationale: Reduces trauma, risk of bleeding or hematoma formation.
·        Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis or melena.
·        Rationale: Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.
·        Keep patient NPO as necessary.
·        Rationale: Decreases GI secretions and motility.
·        Insert NG tube, connect to suction, and maintain patency as indicated.
    • Rationale: To rest the GI Tract

2.   Nursing Diagnosis
  • Pain, acute
May be related to
  • Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis
Possibly evidenced by
  • Reports of pain, biliary colic (waves of pain)
  • Facial mask of pain; guarding behavior
  • Autonomic responses (changes in BP, pulse)
  • Self-focusing; narrowed focus
Desired Outcomes
  • Report pain is relieved/controlled.
  • Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing Interventions
·        Observe and document location, severity (0–10 scale), and character of pain (steady, intermittent, colicky).
·        Rationale: Assists in differentiating cause of pain, and provides information about disease progression and resolution, development of complications, and effectiveness of interventions.
·        Note response to medication, and report to physician if pain is not being relieved.
·        Rationale: Severe pain not relieved by routine measures may indicate developing complications or need for further intervention.
·        Promote bedrest, allowing patient to assume position of comfort.
·        Rationale: Bedrest in low-Fowler’s position reduces intra-abdominal pressure; however, patient will naturally assume least painful position.
·        Use soft or cotton linens; calamine lotion, oil bath; cool or moist compresses as indicated.
·        Rationale: Reduces irritation and dryness of the skin and itching sensation.
·        Control environmental temperature.
·        Rationale: Cool surroundings aid in minimizing dermal discomfort.
·        Encourage use of relaxation techniques. Provide diversional activities.
·        Rationale: Promotes rest, redirects attention, may enhance coping.
·        Make time to listen to and maintain frequent contact with patient.
·        Rationale: Helpful in alleviating anxiety and refocusing attention, which can relieve pain.
·        Maintain NPO status, insert and/or maintain NG suction as indicated.
·        Rationale: Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions.
·        Administer medications as indicated:
·        Anticholinergics: atropine, propantheline (Pro-Banthı-ne);
·        Rationale: Relieves reflex spasm and smooth muscle contraction and assists with pain management.
·        Sedatives: phenobarbital;
·        Rationale: Promotes rest and relaxes smooth muscle, relieving pain.
·        Narcotics: meperidine hydrochloride (Demerol), morphine sulfate;
·        Rationale: Given to reduce severe pain. Morphine is used with caution because it may increase spasms of the sphincter of Oddi, although nitroglycerin may be given to reduce morphine-induced spasms if they occur.
·        Monoctanoin (Moctanin);
·        Rationale: This medication may be used after a cholecystectomy for retained stones or for newly formed large stones in the bile duct. It is a lengthy treatment (1–3 wk) and is administered via a nasal-biliary tube. A cholangiogram is done periodically to monitor stone dissolution.
·        Smooth muscle relaxants: papaverine (Pavabid), nitroglycerin, amyl nitrite;
·        Rationale: Relieves ductal spasm.
·        Chenodeoxycholic acid (Chenix), ursodeoxycholic acid (Urso, Actigall);
·        Rationale: These natural bile acids decrease cholesterol synthesis, dissolving gallstones. Success of this treatment depends on the number and size of gallstones (preferably three or fewer stones smaller than 20 min in diameter) floating in a functioning gallbladder.
·        Antibiotics.
·        Rationale: To treat infectious process, reducing inflammation.

3.   Nursing Diagnosis
  • Nutrition: Less Than Body Requirements, Risk for Imbalanced
Risk factors may include
  • Self-imposed or prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain
  • Loss of nutrients; impaired fat digestion due to obstruction of bile flow
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Report relief of nausea/vomiting.
  • Demonstrate progression toward desired weight gain or maintain weight as individually appropriate.
Nursing Interventions
·        Calculate caloric intake. Keep comments about appetite to a minimum.
·        Rationale: Identifies nutritional deficiencies and/or needs. Focusing on problem creates a negative atmosphere and may interfere with intake.
·        Weigh as indicated.
·        Rationale: Monitors effectiveness of dietary plan.
·        Consult with patient about likes and dislikes, foods that cause distress, and preferred meal schedule.
·        Rationale: Involving patient in planning enables patient to have a sense of control and encourages eating.
·        Provide a pleasant atmosphere at mealtime; remove noxious stimuli.
·        Rationale: Useful in promoting appetite/reducing nausea.
·        Provide oral hygiene before meals.
·        Rationale: A clean mouth enhances appetite.
·        Offer effervescent drinks with meals, if tolerated.
·        Rationale: May lessen nausea and relieve gas. Note:May be contraindicated if beverage causes gas formation/gastric discomfort.
·        Assess for abdominal distension, frequent belching, guarding, reluctance to move.
·        Rationale: Nonverbal signs of discomfort associated with impaired digestion, gas pain.
·        Ambulate and increase activity as tolerated.
·        Rationale: Helpful in expulsion of flatus, reduction of abdominal distension. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility (pneumonia, thrombophlebitis).
·        Consult with dietitian or nutritional support team as indicated.
·        Rationale: Useful in establishing individual nutritional needs and most appropriate route.
·        Begin low-fat liquid diet after NG tube is removed.
·        Rationale: Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence.
·        Advance diet as tolerated, usually low-fat, high-fiber. Restrict gas-producing foods (onions, cabbage, popcorn) and foods or fluids high in fats (butter, fried foods, nuts).
·        Rationale: Meets nutritional requirements while minimizing stimulation of the gallbladder.
·        Administer bile salts: Bilron, Zanchol, dehydrocholic acid (Decholin), as indicated.
·        Rationale: Promotes digestion and absorption of fats, fat-soluble vitamins, cholesterol. Useful in chronic cholecystitis.
·        Monitor laboratory studies: BUN, prealbumin, albumin, total protein, transferrin levels.
·        Rationale: Provides information about nutritional deficits or effectiveness of therapy.
·        Provide parenteral and/or enteral feedings as needed.
·        Rationale: Alternative feeding may be required depending on degree of disability and gallbladder involvement and need for prolonged gastric rest.

4.   Nursing Diagnosis
  • Deficient Knowledge
May be related to
  • Lack of knowledge/recall
  • Information misinterpretation
  • Unfamiliarity with information resources
Possibly evidenced by
  • Questions; request for information
  • Statement of misconception
  • Inaccurate follow-through of instruction
  • Development of preventable complications
Desired Outcomes
  • Verbalize understanding of disease process, prognosis, potential complications.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions
·        Explain reasons for test procedures and preparations as needed.
·        Rationale: Information can decrease anxiety, thereby reducing sympathetic stimulation.
·        Review disease process and prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern.
·        Rationale: Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing.
·        Review drug regimen, possible side effects.
·        Rationale: Gallstones often recur, necessitating long-term therapy. Development of diarrhea or cramps during chenodiol therapy may be dose-related or correctable. Note: Women of childbearing age should be counseled regarding birth control to prevent pregnancy and risk of fetal hepatic damage.
·        Discuss weight reduction programs if indicated
·        Rationale: Obesity is a risk factor associated with cholecystitis, and weight loss is beneficial in medical management of chronic condition.
·        Instruct patient to avoid food/fluids high in fats (pork, gravies, nuts, fried foods, butter, whole milk, ice cream), gas producers (cabbage, beans, onions, carbonated beverages), or gastric irritants ( spicy foods, caffeine, citrus).
·        Rationale: Limits or prevents recurrence of gallbladder attacks.
·        Review signs and symptoms requiring medical intervention: recurrent fever; persistent nausea and vomiting, or pain; jaundice of skin or eyes, itching; dark urine; clay-colored stools; blood in urine, stools, vomitus; or bleeding from mucous membranes.
·        Rationale: Indicative of progression of disease process and development of complications requiring further intervention.
·        Recommend resting in semi-Fowler’s position after meals.
·        Rationale: Promotes flow of bile and general relaxation during initial digestive process.
·        Suggest patient limit gum chewing, sucking on straw and hard candy, or smoking.
·        Rationale: Promotes gas formation, which can increase gastric distension and discomfort.
·        Discuss avoidance of aspirin-containing products, forceful blowing of nose, straining for bowel movement, contact sports.
·        Rationale: Reduces risk of bleeding related to changes in coagulation time, mucosal irritation, and trauma.
·        Recommend use of soft toothbrush, electric razor.
·        Rationale: Reduces risk of bleeding related to changes in coagulation time, mucosal irritation, and trauma.