I. Behavior Responses - Observable Responses of the Individual to Life
Stressors 40%
II. Regulatory Mechanisms 25%
III. Metabolic Mechanisms 25%
IV. Congenital Anomalies, Genetic Disorders, and Developmental Problems
10%
I. Behavior Responses - Observable Responses of the Individual to Life
Stressors 40%
A. Theoretical framework - basis for care
1. Types of behavioral responses
a. Affective responses
1) Persons who exhibit loss/grief responses, including denial,
anger, and bargaining (fore example: persons who have
experienced sudden infant death syndrome [SIDS], a patient
recently diagnoses with chronic renal failure)
2) Persons who exhibit elated behavior, including psychomotor
hyperactivity, euphoria, and flight of ideas
3) Persons who exhibit depressed behavior, including psychomotor
retardation, disruption in sleep and eating patterns, social
isolation, and disturbances in self-esteem
4) Persons who exhibit behaviors indicative of bipolar moods,
including elation/depression
b. Anxiety responses
1) Persons who exhibit anxiety responses (for example: persons
with generalized anxiety disorder, post-traumatic stress disorder,
panic disorder, obsessive compulsive disorder, specific phobia, and
social phobia)
2) Persons who express anxiety through dissociative disorders (for
example: amnesia, fugue, dissociative identity disorder)
d. Withdrawal responses - psychogenic withdrawal from reality,
including delusions, hallucinations, paranoid behavior, and autistic
behavior (for example: schizophrenia and other psychotic disorders)
e. Aggressive responses
1) Persons who demonstrate self-destructive behavior, including
suicide, substance abuse, and eating disorders
2) Persons who demonstrate antisocial behavior (for example:
those who abuse or neglect adults and children, those with
personality disorders)
f. Disruptive responses (for example: attention-deficit hyperactivity,
conduct disorder)
g. Dysfunctional coping behaviors in response to situational crises,
including anger, withdrawal, denial, and dissociation (for example: as
manifested by victims of rape, child abuse, spouse abuse, and elder
abuse)
h. Alterations in behavior related to organic mental disorders, including
delirium, memory impairment. loss of impulse control, and wandering
(for example: dementia of the Alzheimer's type, vascular dementia,
dementia due to HIV disease, Wernicke-Korsakoff syndrome,
Huntington's chorea)
2. Factors influencing an individual's behavioral responses
a. Personality characteristics (for example: introverted, suspicious, rigid,
passive, aggressive)
b. Developmental level (for example: trust vs. mistrust; oral stage)
c. Use of defense mechanisms (for example: denial, projection,
regression)
d. Interpersonal experiences (for example: family roles and
relationships, peer relationships)
e. Socioeconomic and cultural factors (for example: race, religion,
nationality, lifestyle, environmental factors, occupation, education)
f. Precipitating event (for example: rape, divorce, illness, situational and
maturational crises)
g. Genetic background (for example: bipolar disorders, alcoholism,
Alzheimer's disease)
h. Substance abuse (for example: food, alcohol, chemical agents)
i. Nutritional status (for example: potassium imbalance)
3. Theoretical concepts that help explain variations in
behavioral responses (This area includes general concepts
developed by the individuals listed, but not specific
quotations from these individuals)
d. Community mental health programs (for example: Overeaters
Anonymous, Alcoholics Anonymous)
e. Behavior modification therapy
f. Individual psychotherapy
g. Group psychotherapy
h. Family therapy
i. Occupational/recreational therapy
j. Reminiscing therapy
k. Relaxation therapy
l. Cognitive therapy
m. Detoxification programs
n. Somatic therapies
1) Psychopharmacology
(a) Antipsychotic drugs
(b) Antianxiety/antihistamines
(c) Antidepressant drugs
(d) Antimanic drugs (lithium)
(e) Antiparkinsonian drugs
(f) Central nervous system stimulants
(g) Anticonvulsant drugs
2) Electroconvulsive therapy
3) Phototherapy
B. Nursing care related to theoretical framework
1. Assessment - gather and synthesize data about the
patient's health status in relation to the patient's functional
health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: subjective
symptoms, medications, diet, past illnesses, health habits, family
history, usual coping mechanisms)
2) Assess factors influencing the patient's behavioral responses
(see IA2)
3) Obtain objective data related to the patient's behavioral
responses (for example: body language, affect, personal
appearance, psychomotor activity, ritualistic behaviors,
communication patterns, mental status)
4) Review laboratory and other diagnostic data (for example:
dexamethasone levels, lithium levels, electroencephalogram [EEG])
b. Synthesize assessment data (see IB1a[1-4])
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example:
disturbance in self-concept related to biochemical imbalance; ineffective
individual coping related to maturational crisis; delusion and/or
hallucinations; risk for violence related to impaired ability to control
aggression, altered nutrition: less than body requirements related to
reluctance to eat)
b. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for care (for
example: patient will verbalize perception of body image that is
congruent with reality, patient will verbalize feelings of anger and loss,
patient will seek assistance when delusions become threatening, patient
will not harm self or others, patient will gain one pound in three days)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's behavioral responses in
planning patient care (see IA2)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: help the
patient explore negative self-perceptions, provide a non threatening
environment for the patient to practice risk-taking, do not reinforce the
patient's delusions through discussion or validation, reduce
environmental stimulation)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to provide for the patient's physiological needs
(for example: monitor vital signs, provide dietary instruction for
patients with stress-related gastrointestinal problems, monitor
elimination patterns of the depressed patient)
b. Use therapeutic communication skills (for example: to clarify the
patient's thinking, to encourage a higher level of functioning)
c. Use nursing measures to provide for patient safety (for example:
provide a structured milieu, observe suicide precautions, apply
restraints, decrease or increase environmental stimuli, provide for
patient safety before and after electroconvulsive therapy [ECT], prevent
destructive activity through use of de-escalation techniques)
d. Use nursing measures to increase the patient's level of functioning
(for example: encourage participation in patient government, encourage
involvement in reality orientation groups, use music therapy, use group
therapy, use reminiscing therapy, encourage activities of daily living
[ADLs] for the patient with Alzheimer's disease)
e. Use nursing measures to provide the patient with alternate methods
of dealing with stressors (for example: encourage patient's interest in
hobbies, encourage verbalization of thoughts and feelings, encourage the
patient with depression to externalize anger, assist the patient to
develop or strengthen support systems, provide age-appropriate
diversionary activities)
f. Use nursing measures to assist the patient to maintain optimal
function (for example: refer patient to Alcoholics Anonymous,
Overeaters Anonymous; encourage participation in supportive
psychotherapy or family therapy)
g. Use nursing measures specific to prescribes medications (for example:
monitor compliance with monoamine oxidase [MAO] diet, monitor the
intake and output of the patient receiving lithium, monitor for side
effects of medications)
h. Provide information and instruction (for example: instruct the patient
regarding relaxation techniques, provide information about problems-
solving techniques, provide instruction regarding the need for
compliance with lithium therapy)
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and the
expected outcomes
a. Assess and report the patient's response to nursing actions (for
example: verbalized freely, anxiety decreased from +3 to +1, gained
weight, assumed responsibility for personal hygiene, increased acting
out in group)
b. Revise the patient's plan of care as necessary (for example: encourage
the patient to take more responsibility in patient government as self-
esteem increases, recommend an increase in the patient's privileges,
introduce the patient to social interaction in groups, renegotiate no-
suicide contract)
II. Regulatory Mechanisms (25%)
This area includes the adrenal gland, thyroid gland, pituitary gland,
parathyroid gland, and kidney. This area focuses on the nursing care of
patients with health problems such as myxedema, Graves' disease,
Cushing's syndrome, Addison's disease, pheochromocytoma, diabetes
insipidus, acromegaly, nephrotic syndrome, renal calculi, and renal
failure.
A. Theoretical framework - bases for care
1. Types of regulatory disorders
a. Disorders related to excess production of hormones (for example:
pheochromocytoma, Graves' disease, Cushing's syndrome, acromegaly)
b. Disorders related to deficient production of hormones (for example:
myxedema, Addison's disease, diabetes insipidus, hypoparathyroidism)
c. Disorders related to impaired renal function (for example: acute and
chronic renal failure, renal calculi, glomerulonephritis, nephrosis,
nephrotic syndrome)
2. Clinical manifestations of regulatory disorders
a. Altered respiratory functioning (for example: dyspnea, crackles,
wheezes, hypoventilation)
b. Altered circulatory functioning (for example: tachycardia,
hypertension, bradycardia, hypotension)
c. Altered nutrition (for example: weight loss, weight gain)
d. Health instruction (for example: rationale for lifestyle changes, risk
factors, preventive measures)
B. Nursing care related to theoretical framework
1. Assessment - gather and synthesize data about the
patient's health status in relation to the patient's functional
health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: subjective
symptoms, diet, medications, past illnesses, family history, impact
of illnesses on family/occupational roles and self-image)
2) Assess factors influencing the patient's response to regulatory
disorders (see IIA3)
3) Obtain objective data related to the patient's regulatory disorder
(for example: alterations in the vital signs, integument, sleep
patterns, intake and output)
4) Review laboratory and other diagnostic data (for example; urine
tests, hormone levels, blood chemistry, scans, biopsies)
b. Synthesize assessment data (see IIB1a[1-4])
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example:
disturbance in body image related to change in appearance, activity
intolerance related to fatigue, ineffective individual coping related to
inability to manage stressors, impaired gas exchange related to fluid
overload)
b. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for patient care
(for example: patient will participate in grooming, patient will increase
participation in activities, patient will identify one significant stressors,
patient's arterial blood gas values will be within normal limits)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to regulatory
disorders (see IIA3)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: plan time for
the patient to verbalize feelings about changed appearance, schedule
rest periods, select relaxation techniques that are appropriate for the
patient, plan a fluid restriction schedule)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to provide a safe environment (for example:
provide suction apparatus for the patient following a thyroidectomy,
regulate environmental temperature for the patient with myxedema,
provide instruction about implications of corticosteroid regimen)
b. Use nursing measures to promote comfort (for example: provide
temperature control for a patient with Graves' disease, provide skin
care for a patient with pruritus)
c. Use nursing measures specific to prescribed medications (for example:
monitor blood glucose in a patient who is receiving corticosteroid
medication, monitor cardiac function in a patient who is receiving a
thyroid medication, monitor calcium levels in a patient who is receiving
parathyroid hormone)
d. Use nursing measures to prevent/minimize complications due to
regulatory disorders ( for example: closely observe the patient following
a thyroidectomy, monitor bowel elimination for the patient with
myxedema)
e. Use nursing measures to enhance utilization of coping mechanisms
and support systems (for example: encourage verbalization of feelings
about changed body image; provide information about home, health
agencies, social services)
f. Provide information and instruction (for example: provide the
patient's family with information regarding condition and treatment to
enhance patient compliance, provide instruction about dietary
management for the patient with impaired renal function)
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and the
expected outcomes
a. Assess and report the patient's response to nursing actions relative to
the expected outcomes (for example: increased activity levels in the
patient with hypothyroidism, weight loss or gain for a child with
nephrotic syndrome, decreased pain in the patient with renal calculi)
b. Revise the patient's plan of care as necessary (for example: increase
observation of the patient showing signs of impending thyroid crisis,
raise the room temperature for the patient with myxedema, explore the
patient's reasons for noncompliance with dietary regimen)
III. Metabolic Mechanisms (25%)
This area includes the liver, gallbladder, and pancreas. This area
focuses on the nursing care of patients with health problems such as
cirrhosis, cholecystitis, insulin-dependent diabetes mellitus (type I),
noninsulin-dependent diabetes mellitus (type II), pancreatitis, and
cholelithiasis
A. Theoretical framework - basis for care
1. Types of metabolic disorders
a. Responses to obstruction (for example: cholelithiasis, pancreatitis,
cholecystitis)
b. Responses to toxic substances (for example: chronic pancreatitis,
cirrhosis, hepatic coma)
c. Responses to inadequate production of utilization of secretions (for
example: insulin-dependent diabetes mellitus [type I], noninsulin-
dependent diabetes mellitus [type II])
2. Clinical manifestations of metabolic disorders
a. Altered fluid and electrolyte balance (for example: polyuria,
polydipsia, muscle weakness, bradycardia, shallow respirations,
diarrhea, hypotension, edema, cardiac dysrhythmia)
b. Altered nutrition (for example: anorexia, nausea, vomiting,
polyphagia, dyspepsia)
c. Altered elimination (for example: clay colored stool, frothy urine)
d. Altered appearance (for example: edema, ascites, jaundice, spider
nevi)
e. Altered neurological function (for example: lethargy, memory loss,
behavioral changes, decreased sensory perception, changes in fine
motor control)
f. Altered comfort (for example: pain, fatigue)
g. Altered activity (for example: changes in sleep patterns, fatigue)
h. Altered respiratory function (for example: Kussmaul's respiration,
dyspnea)
i. Altered circulatory function (for example: hypotension, tachycardia)
j. Altered integument (for example: pururitus, poor wound healing)
3. Factors influencing the patient's response to metabolic
disorders
a. Age and physiological factors (for example: allergies)
b. Psychological factors (for example: stress, cognitive ability, body
image, coping mechanisms)
c. Nutritional status (for example: obesity, malnutrition)
d. Presence of other illnesses (for example: infection, chronic illnesses)
e. Socioeconomic and cultural factors (for example: health practices,
lifestyle, occupation, education, environmental factors)
f. Availability of support systems (for example: family, friends,
community resources)
4. Theoretical basis for interventions related to metabolic
disorders
b. Preoperative and postoperative care (for example: cholecystectomy
[abdominal and lparoscopic], choledochostomy)
c. Treatment modalities (for example: diabetic exchange diet, low-
protein diet, double-balloon tamponade)
d. Health instruction (for example: rationale for preventive measures,
lifestyle changes, risk factors)
B. Nursing care related to theoretical framework
1. Assessment - gather and synthesize data about the
patient's health status in relation to the patient's functional
health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: subjective
symptoms, diet, medications, drug and alcohol use, past illnesses,
family history, allergies, impact of illnesses on
family/occupational roles)
2) Assess factors influencing the patient's response to metabolic
disorders (see IIIA3)
3) Obtain objective data related to the patient's metabolic disorder
(for example: alterations in vital signs, integument, weight,
abdominal girth, psychomotor function)
4) Review laboratory and diagnostic data (for example: blood
chemistry, serum enzyme levels, liver function studies, biopsy,
scans, glycosylated hemoglobin)
b. Synthesize assessment data (see IIIB1a[1-4])
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example: risk for
injury: bleeding related to vitamin K deficiency; ineffective breathing
pattern related to incisional pain; altered nutrition: less than body
requirements related to vomiting and anorexia; noncompliance related
to denial of illness; knowledge deficit: administration of insulin related
to lack of information; risk for injury related to confusion)
b. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for care (for
example: patient will not experience bleeding, patient will list foods
high in sodium, patient will increase caloric intake to 2,000 calories,
patient will demonstrate correct administration of insulin, patient will
remain free of injury)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to metabolic
disorders (see IIIA3)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: plan to instruct
the patient about safe oral hygiene practices, plan to provide the patient
with a list of high-sodium foods, plan to provide oral care frequently,
plan to show the patient a videotape regarding the administration of
insulin, plan protective measures)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to provide a safe environment (for example:
provide the patient with a soft toothbrush, pad the siderails for a
patient who is confused, eliminate obstacles from the ambulatory path
of a patient with neuropathy)
b. Use nursing measures to promote comfort (for example: place the
patient with ascites in position of comfort, administer medications for
pain relief, control the environmental temperature for the patient with
pruritus, provide mouth care for a patient with a double-balloon
tamponade)
c. Use nursing measures specific to prescribed medications (for example:
monitor serum glucose for a patient who is receiving insulin, monitor
electrolytes for a patient who is receiving diuretics, monitor serum
prothrombin times for a patient who is receiving vitamin K, monitor
pulse for a patient who is receiving propranolol)
d. Use nursing measures to prevent/minimize complications due to
metabolic disorders (for example: provide skin and nail care for the
patient with diabetes mellitus, rotate insulin sites for the patient with
diabetes mellitus, use small-gauge needles for injections for the patient
with bleeding tendencies, apply pressure to injection sites for 5-10
minutes to minimize bleeding tendencies, test the stool of a patient with
a bleeding disorder for occult blood, monitor bleeding following
biopsies)
e. Use nursing measures to enhance utilization of coping mechanisms
and support systems (for example: provide information about available
age-appropriate support services, such as camps for children with
diabetes mellitus; encourage the patient and family to participate in
decision making: encourage verbalization of feelings related to the grief
process and loss of function)
f. Use nursing measures to provide information and instruction (for
example: review predisposing factors with the patient with noninsulin-
dependent diabetes mellitus [type II], instruct the patient with cirrhosis
to read labels when shopping for food, encourage the patient with
diabetes mellitus to schedule and annual eye examination, instruct the
patient with diabetes mellitus about foot care)
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and expected
outcomes
a. Assess and report the patient's response to nursing actions (for
example: appetite has changed, nausea and vomiting is relieved, patient
reports relief from pain, bleeding is minimized, skin is intact, weight is
stable)
b. Revise the patient's plan of care as necessary (for example: consider
alternate methods of pain relief to enhance medication effectiveness,
increase observation of a patient with an increased serum amylase
level, reevaluate fluid and nutritional intake when a patient with
cirrhosis continues to gain weight, review the diet and exercise program
of a patient with diabetes mellitus whose glycosylated hemoglobin level
remains elevated)
IV. Congenital Anomalies, Genetic Disorders, and Developmental
Problems (10%)
This area includes congenital anomalies, which are those acquired
during fetal development in utero; genetic disorders, which are
hereditary in nature; and developmental problems, which interfere with
normal growth and development. This area focuses on the nursing care
of patients with health problems such as cardiac anomalies, cystic
fibrosis, hemophilia, hydrocephalus, Down syndrome, phenylketonuria
(PKU), meningomyelocele (spina bifida), muscular dystrophy, cerebral
palsy, clubfoot, developmental dysplasia of the hip, Hirschsprung's
disease, tracheoesophageal fistula, imperforate anus, congenital heart
disease, biliary atresia, and mental retardation.
A. Theoretical framework - basis for care
1. Types of congenital anomalies, genetic disorders, and
developmental problems
a. Problems affecting oxygenation (for example: tetralogy of Fallot,
patent ductus arteriosus, cystic fibrosis, hemophilia, sickle cell anemia)
e. Health instruction (for example: rationale for preventive measures,
risk factors)
B. Nursing care related to theoretical framework
1. Assessment - gather and synthesize data about the
patient's health status in relation to the patient's functional
health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: subjective
symptoms, diet, medications, past illnesses, family history,
developmental tack achievement, sleeping patterns,
immunizations, growth and developmental data)
2) Assess factors influencing the patient's response to congenital
anomalies and genetic problems (see IVA3)
3) Obtain objective data related to the patient's health problem
(for example: breath sounds, altered integument, gait,
developmental task achievement, growth rate, sensory-motor
ability, physical abnormalities, altered vital signs, general
appearance, head size, energy level)
4) Review laboratory and other diagnostic data (for example: chest
X ray, skeletal X ray, sweat test, complete blood count [CBC],
arterial blood gases [ABG], electrocardiogram [EKG], barium enema,
ultrasound, magnetic resonance imaging [MRI])
b. Synthesize assessment data (see IVB1a[1-4])
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example: altered
family process related to situational crisis; activity intolerance related to
imbalance between oxygen supply and demand; risk for infection
related to pulmonary congestion; impaired mobility related to
neuromuscular problems; altered cerebral tissue perfusion related to
increased intracranial pressure; altered nutrition: less than body
requirements related to inadequate pancreatic enzymes)
b. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for care (for
example: family will demonstrate understanding of child's abilities,
child will be free of cyanosis during morning care, patient will move
independently with the aid of assistive devices, head circumference will
remain stable, child will be free of irritability and headaches and will
have vital signs within normal limits, patient will be free of abdominal
distention, stools will be brown and of medium consistency and size)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to congenital
anomalies and genetic problems (for example: site of anomaly, severity
of problem, patient's access to health care [see IVA3])
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: plan to change
the child's position frequently, schedule rest periods, establish a
schedule for chest physiotherapy, plan instruction regarding assistive
devices)
4. Implementation - carry out nursing interventions designed
to move the patient toward the expected outcomes
a. Use nursing measures to assist the patient and family to cope with
the disability (for example: use therapeutic communication, make
referrals to support groups)
b. Use nursing measures to promote, maintain, or restore physiological
functioning (for example: establish a rest schedule for the patient with a
cardiac anomaly, provide chest physiotherapy for a patient with cystic
fibrosis, elevate the head of the bed for a patient with hydrocephalus,
position the child with a meningomyelocele on the abdomen)
c. Use nursing measures to stimulate and encourage psychosocial
development (for example: use appropriate verbal communication,
provide assistance and encouragement for the child to perform
developmental tasks, encourage age-appropriate play activities)
d. Use nursing measures to prevent/minimize complications (for
example: monitor vital signs, use sterile technique during dressing
changes, position the child to prevent contamination from urine and
stool)
e. Use nursing measures to provide comfort, rest, and sleep (for
example: maintain bedtime routines; provide a quite, calm environment;
position for comfort; relieve abdominal distention)
f. Use nursing measures specific to prescribed medications (for example:
take the pulse prior to administering digitalis, check for response to
pain-relieving medications, check for allergies prior to administering
antibiotics, administer pancreatic enzymes with meals)
g. Use nursing measures to provide information and instruction (for
example: instruct the family about low-phenylalanine diet, provide skin
care instruction for a patient who is wearing a brace, instruct the family
in positioning techniques for the child with hydrocephalus, instruct the
family in postural drainage techniques)
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and the
expected outcomes
a. Assess and report the patient's response to nursing actions relative to
the expected outcomes (for example: changes in elimination patterns,
head circumference, ability to ingest food; achievement of bowel and
bladder function; achievement of developmental tasks)
b. Revise the patient's plan of care as necessary (for example: consider
addition of percussion to postural drainage program for a child with
cystic fibrosis, obtain self-help devices for the patient with a
progressive coordination disability)
