Nursing
Notes
Nursing
Notes
Contents
Body temperature - clinical assessment and monitoring
(19th November 1998; revised 26th December 1998)
Nurses commonly take and record the peripheral body temperature - this is one of the most common skills a nurse will perform. Often the temperature is taken whilst collecting other clinical data from the patient in order to determine the extent of any homeostatic imbalances or to assess an individual's response to a medical or nursing intervention. Other observations include taking and recording the pulse and blood pressure, and if the person has just been admitted into hospital, testing and charting a specimen of urine and recording the individual’s weight. Observations such as these are regarded as objective assessments.
The peripheral body temperature is often measured orally with a standard glass clinical thermometer. This is placed under the person's tongue (sublingually) on one side or the other of the midline frenulum. However, this method may not always be possible, for example in the very young, those who are unable to co-operate, an unconscious patient, or someone who has trauma to the face and/or oral cavity, and other routes are used. Suitable alternatives are the axilla (armpit) and rectum.
How long should the thermometer remain in position?
The accuracy of the readings obtained will be greatly influenced by the length of time the thermometer is left in position:
'Many workers have examined this question and suggest various times for the different sites used. Nichols and her colleagues have undertaken some of the most comprehensive work in this area (Nichols et al, 1996; Nichols, 1972; Nichols et al, 1972). It was found that it took between 1-12 minutes for oral or axillary placements and 1-9 minutes for rectal placements to record the maximum temperature measurement. The commonly used 3-minute timing led to marked inaccuracy. It was recommended that the thermometer should be left in position for 7- 8 minutes in the mouth, 9 minutes in the axilla or 2 minutes in the rectum. The use of these timings will mean that in 90% of the recordings made, the reading will be within 0.1°C of the maximum reading which could be achieved.'
Boore, Champion, and Ferguson, 1987 (page 878).
Temperature measurements at different locations
If the axilla is chosen it is important to ensure that the bulb of the thermometer actually touches the skin’s surface, because in some very thin people the axilla can be quite hollow. If a rectal recording is to be made it is important to use a rectal thermometer - these have a blue bulb and are kept separately.
Before taking the temperature sublingually, it is essential to ensure that no hot or cold food or drink has been consumed beforehand and that the person has not been involved in vigorous exercise. If the person smokes it will be important to allow at least fifteen minutes to lapse following the last cigarette before taking the temperature. A clear polythene sleeve is placed over the thermometer before placing it into the patient's mouth. Breathing through the nose will be necessary whilst the thermometer is in place.
The length of time needed to achieve an accurate sublingual recording has been the subject of much debate. Research by Nichols and Kucha (1972) showed that at 'normal' room temperature a clinical thermometer should ideally be left in place for eight minutes for men and nine minutes for women. In clinical practice however four minutes is the generally accepted time span.
Immediately following removal of the thermometer from the individual's mouth the polythene sleeve is discarded and the reading is taken. The thermometer is held horizontally at eye level and rotated until the column of mercury can be seen. The level of the mercury is then compared with the graduations on the thermometer. After the reading has been obtained the thermometer is shaken down and placed back inside the holder. The temperature is recorded.
The intervals between temperature measurements will depend on the patient's condition. They may be carried out as frequently as half hourly, for example when a patient is receiving a blood transfusion (although hospital policies may vary slightly here), to daily in someone whose condition has improved and stabilised.
Battery powered and disposable thermometers are now in common use. These have the advantage of providing more rapid results, from 45 seconds to almost immediate readings.
|
Peripheral Temperature - 'Normal' Ranges |
|
| Oral (Sublingual) | 36 - 37 ° C |
| Axillary | 36.4 ° C |
| Rectal | 37.6 ° C |
(Research by Boore et al., 1987 questions the commonly-held assumption that the rectal temperature is slightly higher than the oral temperature, and the axillary temperature slightly lower.)
Common Terms
Anti Pyretics - a group of drugs that bring about a fall in body temperature. Such drugs are based on acetylsalicylic acid (aspirin). anti pyretics - a group of drugs that bring about a fall in body temperature. Such drugs are based on acetylsalicylic acid (aspirin).
Core Temperature - the temperature of the organs within the central part of the body: brain, heart, lungs, and abdominal organs. The core temperature remains relatively constant in the range 36.1 - 37.8 ° C. core temperature - the temperature of the organs within the central part of the body: brain, heart, lungs, and abdominal organs. The core temperature remains relatively constant in the range 36.1 - 37.8 ° C.
Hyperpyrexia - a term used to describe a temperature above 41 ° C. hyperpyrexia - a term used to describe a temperature above 41 ° C.
Hypothermia - a term used to describe a fall in the peripheral temperature to below 35 ° C. hypothermia - a term used to describe a fall in the peripheral temperature to below 35 ° C.
Pyrexia (Fever) - elevation of the body temperature up to 41 ° C. (This will occur if the body core temperature rises above - 38 ° C). pyrexia (fever) - elevation of the body temperature up to 41 ° C. (This will occur if the body core temperature rises above - 38 ° C).
References
Boore, J.R.P., Champion, R., and Ferguson, M.C. (editors) (1987) Disturbances of temperature control. In: Nursing the physically ill adult: a textbook of medical-surgical nursing. Edinburgh: Churchill Livingstone.
Nichols, G.A. (1972) Time analysis of afebrile and febrile temperature readings. Nursing Research, 21, 463 - 464.
Nichols, G.A., Ruskin, M.M., Glor, B.A.K., and Kelly, W.H. (1996) Oral, axillary and rectal temperature determinations and relationships. Nursing Research, 15, 307- 309
Nichols, G.A., Kucha, D.H., and Mahoney, R.P. (1972) Rectal thermometer placement times for febrile adults. Nursing Research, 21, 76 - 77.
Nichols G.A. and Kucha D.H. (1972) Taking adult temperatures: oral measurements. American Journal of Nursing, 1972, 1091-1092.
(19th November 1998)
Paralytic Ileus (Adynamic Obstruction)
After abdominal surgery peristalsis may cease and bowel sounds remain absent for a few days. This is due to cessation of activity in the myenteric plexus and the absence of parasympathetic nerve impulses to the smooth muscle of the intestinal tract. Anaesthetic agents are thought to contribute to this state of localised paralysis.
A naso-gastric tube is inserted (now normally at the time of the operation) to enable the problem to be managed postoperatively. In effect the naso-gastric tube drains the gastro-intestinal tract thereby preventing abdominal distension and the uncomfortable feelings of nausea. The exhaustion which vomiting produces, not to mention the serious complications that will arise if inhalation of vomitus occurs, are thus prevented. In many ways, although people who have had nasogastric tubes inserted may disagree, the procedure actually facilitates rest - rest to the gastrointestinal tract and rest to the whole body both mentally and physically. Evidence suggests that rest helps healing. Therefore taken along with other nursing measures that are performed during the immediate post operative period to achieve rest, the nasogastric tube and the procedure of gastric aspiration play an important part.
Mechanical Obstruction
A nasogastric tube is also used in the management of patients who present with an acute intestinal obstruction, and is used both as a conservative measure and as a preoperative requirement. Some forms of simple obstruction e.g. paralytic ileus or adhesions of the small bowel are treated using a conservative approach coupled with careful observation and monitoring. Obstructions caused by strangulation, perforation, or carcinoma require urgent surgical attention. The nursing care under these circumstances will be aimed at the management of symptoms, the correction of neurogenic and hypovolaemic shock, and preparation for emergency laparotomy.
Fluid replacement will be essential during the period that a person has to endure a nasogastric tube. Initially this will be given by the intravenous route, using mainly crystalloid solutions. As the gastric juices contain potassium this electrolyte will be lost from the body with the aspirate, and will need to be replaced. Therefore the intravenous regime will be likely to include solutions that contain 20mmols of potassium per litre.
Nasogastric tubes are uncomfortable and embarrassing to have inserted and to be attached to. Privacy and sensitivity during the procedure for insertion, when aspirating the tube and during removal is important. Regular attention to the mouth and teeth will help to lessen the discomfort that occurs if the mucus membranes become dry, particularly when a person is not allowed to eat or drink (NBM - ‘nil by mouth’).
Hints & Tips
Tell the person what you are about to do before starting the procedure, whether inserting a nasogastric tube for the first time or carrying out a routine aspiration procedure
Check that the individual’s nostrils are clean before attempting to pass the tube
Where possible, ask the person to take a sip of water whilst inserting the nasogastric tube - this will facilitate entry into the oesophagus by helping to overcome the gag reflex. Forwarding the tube as the person swallows helps to reduce the risk of inadvertent entry into the trachea
Recall that the tip of the nose is a particularly sensitive area.
Check that the tube is in the stomach - normally blue litmus paper is used to determine this ("if blue turns red, acid ‘tis said". Point to ponder - what colour would pink litmus change to?)
Measure the volume of aspirate and chart.
Suggested Reading
Look at the information that accompanies the commonly prescribed anti-emetic preparations and become acquainted with those that act centrally (on the central nervous system) and those that have a combined central and peripheral effect. Note also the unwanted side-effects of such preparations.
Peritoneal adhesions and intestinal obstruction
(24th January 2000)
Abdominal pain (colic), nausea and vomiting are the principal signs and symptoms that occur as a result of intestinal obstruction. In post-operative patients, approximately 90% of mechanical obstructions are due to adhesions (Brunner and Suddarth, 1993). Vomiting, particularly if prolonged, leads to acute fluid loss and also produces electrolyte disturbances as sodium (Na+) and potassium (K+) ions become depleted. Hypovolaemic shock ensues, the effects of which are more pronounced in the very young and the very old. Urgent nursing measures are required and these are aimed towards the relief of symptoms and the correction of shock.
Psychological Needs
Typically a person presenting with acute intestinal obstruction is frightened, anxious, in pain and exhausted. A calm approach by the nurse, giving a brief explanation of the procedures that will be performed helps towards restoring a sense of security. Such an approach also helps towards gaining the person's consent and cooperation, something which is particularly important if the person later has to undergo abdominal surgery.
Physical Needs
Relief of Pain - an opiate preparation is normally administered, by intramuscular injection. The person's response to the analgesic regime is carefully monitored.
Relief of Nausea and Vomiting - nothing is given by mouth (NBM). A naso-gastric tube is passed and the contents of the stomach aspirated. This is potentially a distressing procedure, and strategies to minimise discomfort for the patient have been reviewed recently by Penrod, Morse, and Wilson (1999). The volume of aspirate is measured and charted. Aspirations may be repeated hourly, and/or the naso-gastric tube attached to a polythene tube and bag to achieve siphon drainage. An anti-emetic preparation is usually prescribed and administered intramuscularly. Prochlorperazine is an example of a commonly prescribed anti-emetic. The benefits of this preparation are that the potential side effects of nausea, induced by opioid administration, can be offset. As with the analgesic regime the person's response to the anti-emetic is monitored. Oral hygiene is performed regularly. relief of nausea and vomiting - nothing is given by mouth (NBM). A naso-gastric tube is passed and the contents of the stomach aspirated. This is potentially a distressing procedure, and strategies to minimise discomfort for the patient have been reviewed recently by Penrod, Morse, and Wilson (1999). The volume of aspirate is measured and charted. Aspirations may be repeated hourly, and/or the naso-gastric tube attached to a polythene tube and bag to achieve siphon drainage. An anti-emetic preparation is usually prescribed and administered intramuscularly. Prochlorperazine is an example of a commonly prescribed anti-emetic. The benefits of this preparation are that the potential side effects of nausea, induced by opioid administration, can be offset. As with the analgesic regime the person's response to the anti-emetic is monitored. Oral hygiene is performed regularly.
Fluid Replacement - intravenous fluids are administered e.g. crystalloid solutions, with potassium to correct hypokalaemia. The volume of fluid administered will be according to the person's state of dehydration and degree of hypovolaemia. The amount given is recorded on the fluid balance chart (see notes on calculating intravenous flow rates). fluid replacement - intravenous fluids are administered e.g. crystalloid solutions, with potassium to correct hypokalaemia. The volume of fluid administered will be according to the person's state of dehydration and degree of hypovolaemia. The amount given is recorded on the fluid balance chart (see notes on calculating intravenous flow rates).
Fluid Output - the person's urinary output is measured and recorded. The formation and excretion of urine by the kidneys is principally controlled by aldosterone and antidiuretic hormone (ADH, also called vasopressin). In hypovolaemic shock the amount of aldosterone produced by the adrenal cortex increases, triggered by the conversion of angiotensin I to angiotensin II in the lungs. The net result is that sodium, and therefore water, is retained. The amount of antidiuretic hormone produced by the posterior pituitary gland also increases and the action of ADH on the distal convoluted tubules of the kidneys decreases the amount of fluid passing to the collecting ducts and becoming urine. Examining the concentration of successive urine samples produced by a person in shock can provide a quick indication of progress. Such an observation would however, need to be viewed against other objective recordings, e.g. blood pressure and pulse. fluid output - the person's urinary output is measured and recorded. The formation and excretion of urine by the kidneys is principally controlled by aldosterone and antidiuretic hormone (ADH, also called vasopressin). In hypovolaemic shock the amount of aldosterone produced by the adrenal cortex increases, triggered by the conversion of angiotensin I to angiotensin II in the lungs. The net result is that sodium, and therefore water, is retained. The amount of antidiuretic hormone produced by the posterior pituitary gland also increases and the action of ADH on the distal convoluted tubules of the kidneys decreases the amount of fluid passing to the collecting ducts and becoming urine. Examining the concentration of successive urine samples produced by a person in shock can provide a quick indication of progress. Such an observation would however, need to be viewed against other objective recordings, e.g. blood pressure and pulse.
Diagnosing whether the cause of the person's acute abdominal problems are due to adhesions is the responsibility of the doctor. Physical examination, erect and supine abdominal X-rays are two approaches that help towards establishing a cause. The nurse is responsible for instigating procedures designed to stabilise the person's shocked state, and if necessary prepare the person for surgery. If a diagnosis of adhesions is made, conservative measures are initially employed. Close collaboration with the surgical team enables care to be delivered efficiently and effectively.
References
Brunner, L.S., and Suddarth, D. (1993) The Lippincott manual of medical and surgical nursing (2nd edition). Chapman and Hall (Care of the patient with a gastro-intestinal disorder, p 488).
Hinds, C.J. (1987) Intensive care: a concise textbook (1st edition). Baillère Tindall (Shock, pathophysiology, p130).
Penrod, J., Morse, J., and Wilson, S. (1999) Comforting strategies used during nasogastric tube insertion. Journal of Clinical Nursing, 8, 31-38.
Please could you tell me how to care for a patient in the community who is having visits to the hospital for chemotherapy? And how to care for a patient in the hospital who has cancer and is having radiotherapy?
30th March 2000
These are very broad topics. The care that each person receives will depend upon their: age, sex, marital state, diagnosis, pre-existing state of health, both mental and physical, and the strength of any social support networks that exists. The understanding the person has concerning their illness and forms of treatment, coupled with their attitude towards these are other important considerations.
A patient in the community visiting a hospital for chemotherapy
First of all it will be worthwhile obtaining information from the hospital team concerning the aims of the chemotherapy e.g. curative, to achieve control, or to achieve palliation. In addition the drug/s being used, the method of administration, the frequency of administration together with the unwanted side effects of these drugs. It is worth bearing in mind that in addition to treating the disease, chemotherapy has the potential to disrupt homeostasis in normal healthy tissues. Attention needs to be given towards any drugs prescribed to counter such side effects as it is common practice to plan the management of acute, delayed and anticipatory symptoms before the commencement of chemotherapy.
With this background knowledge a suitable plan of individualised care can be developed. Keep in mind that integral to any framework of care is the need to uphold continuity and compliance with treatment.
Psychological Support
Assess the person's level of
understanding and if necessary correct any misconceptions whilst at the same
time reinforcing areas of knowledge that are correct. Also it will be helpful if
information given by the medical and nursing teams can be further explored to
ensure that no misunderstanding exists. Helping the person to retain a sense of
control over their life, to feel able to make choices and take decisions is
important. At the same time communicating a sensitive, dignified approach should
help towards fostering and maintaining feelings of self worth.
physical support: each bodily system should be assessed and the extent to which
the disease imposes on the person's 12 activities of living taken into account
(Roper et al,1983). Activities in which the person is considered to be
independent are maintained, while those that are compromised become the focus
for nursing care. Selective examples (not in any order of priority) are:
Breathing - upper respiratory tract infection: a sore throat can develop and may be due to leukopenia allowing opportunistic infection. Regular warm mouthwashes and gargles often help towards relieving the discomfort caused. Oral toilet needs to be maintained and any oral ulceration noted, reported and treated accordingly. The signs and symptoms of an emerging lower respiratory tract infection eg: fever, productive cough, or malaise need to be taken into account and, if evident, reported to the medical team. breathing - upper respiratory tract infection: a sore throat can develop and may be due to leukopenia allowing opportunistic infection. Regular warm mouthwashes and gargles often help towards relieving the discomfort caused. Oral toilet needs to be maintained and any oral ulceration noted, reported and treated accordingly. The signs and symptoms of an emerging lower respiratory tract infection eg: fever, productive cough, or malaise need to be taken into account and, if evident, reported to the medical team.
Eating and Drinking - the maintenance of a normal diet should be encouraged. Some people experience loss of appetite in which case a modified diet, eg: nutritious drinks, small amounts of food taken slowly, and removing all foods that provoke a sense of nausea are strategies that can be tried. Prescribed antiemetic preparations are given to control nausea and the person's response to these monitored. In terms of fluid intake a volume of around 3 litres over twenty-four hours for an adult would be a desirable aim. Regular weighing will provide a good indication concerning the person's metabolic state. eating and drinking - the maintenance of a normal diet should be encouraged. Some people experience loss of appetite in which case a modified diet, eg: nutritious drinks, small amounts of food taken slowly, and removing all foods that provoke a sense of nausea are strategies that can be tried. Prescribed antiemetic preparations are given to control nausea and the person's response to these monitored. In terms of fluid intake a volume of around 3 litres over twenty-four hours for an adult would be a desirable aim. Regular weighing will provide a good indication concerning the person's metabolic state.
Eliminating - any alterations to the normal pattern of eliminating will need recording and reporting. Diarrhoea can be a late complication with some forms of chemotherapy. A low residue diet and correction of fluid and electrolyte disturbances will be necessary. Constipation can often be relieved by attention to the diet and where possible maintaining exercise. In addition a mild laxative may be necessary. High levels of uric acid excretion can occur leading to uric acid crystal formation and associated renal dysfunction; a complication of treatment for non-Hodgkin's lymphoma and leukaemia (British National Formulary, 1999). Allopurinol is a drug that is frequently prescribed for the control of uric acid levels. Adequate hydration helps towards preventing the formation of uric acid crystals which might cause urinary obstruction. MESNA is a preparation used to prevent urethral toxicity in association with the administration of the cytotoxic preparations cyclophosphamide and ifosfamide (British National Formulary, 1999). eliminating - any alterations to the normal pattern of eliminating will need recording and reporting. Diarrhoea can be a late complication with some forms of chemotherapy. A low residue diet and correction of fluid and electrolyte disturbances will be necessary. Constipation can often be relieved by attention to the diet and where possible maintaining exercise. In addition a mild laxative may be necessary. High levels of uric acid excretion can occur leading to uric acid crystal formation and associated renal dysfunction; a complication of treatment for non-Hodgkin's lymphoma and leukaemia (British National Formulary, 1999). Allopurinol is a drug that is frequently prescribed for the control of uric acid levels. Adequate hydration helps towards preventing the formation of uric acid crystals which might cause urinary obstruction. MESNA is a preparation used to prevent urethral toxicity in association with the administration of the cytotoxic preparations cyclophosphamide and ifosfamide (British National Formulary, 1999).
Personal Cleansing and Dressing - help in maintaining body hygiene, dressing and undressing may be necessary, particularly if the person experiences fatigue and malaise. The skin forms part of the body's external defence mechanisms and therefore needs regular care and protection. People receiving chemotherapy are at risk of developing infection/s and it is essential that their skin is suitably protected from trauma. Not only this but chemotherapeutic agents, like other drugs, can cause skin rashes. Consideration needs to be given towards making appropriate clothing available and, if fatigue is predominant leading to inactivity, that the person is protected from exposure to cold. Keep in mind also that helping a person to maintain their normal pattern of hygiene and dress code contributes greatly to their self-esteem. personal cleansing and dressing - help in maintaining body hygiene, dressing and undressing may be necessary, particularly if the person experiences fatigue and malaise. The skin forms part of the body's external defence mechanisms and therefore needs regular care and protection. People receiving chemotherapy are at risk of developing infection/s and it is essential that their skin is suitably protected from trauma. Not only this but chemotherapeutic agents, like other drugs, can cause skin rashes. Consideration needs to be given towards making appropriate clothing available and, if fatigue is predominant leading to inactivity, that the person is protected from exposure to cold. Keep in mind also that helping a person to maintain their normal pattern of hygiene and dress code contributes greatly to their self-esteem.
Expressing Sexuality - alterations to a person's body image can have a negative effect on the way in which they perceive themselves Chemotherapy can result in different degrees of reversible hair loss (alopecia). Feelings of fatigue and malaise may impede the desire for sexual contact. Sexual intercourse may become difficult or impossible. Other forms of close contact such as holding, hugging and touching can help to offset any feelings of isolation that might otherwise arise. Treatment does not invariably affect sexual relationships. Birth control measures that were previously used should be continued unless otherwise advised by the medical/family planning team. Not everyone will feel comfortable about discussing aspects of their personal relationships. Such feelings will need to be respected but at least the opportunity to do so needs to be made available, providing the nurse is secure and confident with her/his own knowledge. expressing sexuality - alterations to a person's body image can have a negative effect on the way in which they perceive themselves Chemotherapy can result in different degrees of reversible hair loss (alopecia). Feelings of fatigue and malaise may impede the desire for sexual contact. Sexual intercourse may become difficult or impossible. Other forms of close contact such as holding, hugging and touching can help to offset any feelings of isolation that might otherwise arise. Treatment does not invariably affect sexual relationships. Birth control measures that were previously used should be continued unless otherwise advised by the medical/family planning team. Not everyone will feel comfortable about discussing aspects of their personal relationships. Such feelings will need to be respected but at least the opportunity to do so needs to be made available, providing the nurse is secure and confident with her/his own knowledge.
Communicating - it will be important to provide the person with sufficient space and time in which to think and express himself or herself. Attentive listening and observing for non-verbal cues enables insight into the person's thoughts and feelings to be gained. It is important to keep in mind that any sensory loss or impediment can distort a person's perception and understanding. This should be borne in mind and care taken towards minimising the risks of misinterpretation. communicating - it will be important to provide the person with sufficient space and time in which to think and express himself or herself. Attentive listening and observing for non-verbal cues enables insight into the person's thoughts and feelings to be gained. It is important to keep in mind that any sensory loss or impediment can distort a person's perception and understanding. This should be borne in mind and care taken towards minimising the risks of misinterpretation.
Care of someone in hospital receiving radiotherapy
Again much will depend on the individual concerned and their circumstances - the tumour type, its location, and the form of radiotherapy being used eg: external beam, local application of radioisotopes, or systemic radioisotope therapy. The aims of treatment will also need to be kept in mind, whether as primary cure, as adjuvant therapy (before or after surgery), or as palliation. The points made in earlier paragraphs in relation to the care for someone receiving chemotherapy are all pertinent, except here a different form of treatment is being used.
A person confined to hospital and undergoing such treatment would be likely to be nursed on a specialist oncology ward. Nursing care will be directed towards supporting the person psychologically and physically during their stay. Like chemotherapy, radiotherapy can be said to invoke homeostatic imbalances in addition to the therapeutic effect being sought. Nursing care is concerned with minimising the effects of these changes by providing symptomatic relief (pre-emptive as far as possible) in the form of drugs such as anti-emetics, antidiarrhoeal preparations, steroids, and analgesics. Other concerns are provision of a well-balanced and nutritious diet, prevention of dehydration, and protection of the area of skin over which the radiotherapy beam is being directed (light skin tends to be more sensitive than darker skin) in accordance with ward policy. At the same time it is important to maintain the person's need for safety and protection by enabling them to take an active part in their care and become more familiar with the hospital environment.
A nursing model is used to keep the care focused appropriately. Activities in which the person is independent are maintained, and care and support are directed towards areas where independence is either being threatened or has been lost.
Safety-specific precautions need to be upheld when nursing a person who is receiving an internal source of radiation and also when caring for anyone who is receiving unsealed internal radiation such as iodine 131. Locally set guidelines and policies must be adhered to.
Please note - the information provided is not intended to be interpreted as a comprehensive account of the nursing care that a person receiving either chemotherapy or radiotherapy would be likely to receive. A generalised theme has been adopted with the intention of providing insight into the rationale behind some of the aspects of care that are likely to apply.
References
Roper, N., Tierney, A., and Logan, W. (1983) Using a model for nursing. London: Churchill Livingstone.
British National Formulary (1999) Malignant disease and immunosuppression. A joint publication by the British Medical Association and the Royal Pharmaceutical Society of Great Britain. Pharmaceutical Press (pp374-398).