Complementary and Alternative Therapy C. Matthews MSN, RN Marilee Elias, MSN, RN Spring 2012 Please make phones silent & visible Reading Required: – Wilkinson-Ch. 40 – Ignatavicius – Ch. 2 Suggested Additional reading: – Lilley – Ch. 8 “Over the counter drugs and Herbal products” Some references in this presentation will be from pages in your textbooks other than required chapters – highly recommended reading. 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN 2 Course Outcomes 1. Identify the roles of the nurse in a variety of community settings to maintain optimal level of wellness. 2. Client - centered teaching. 3. Apply the nursing process to meet the physiological and psychosocial needs of clients and their families at the end of life. 4. Standards of safe medication administration. 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP10 3 UNIT OUTCOMES 1. Integrate complementary therapies into health promotion activities for the well client. 2. Assess client need for Complementary or Alternative therapy. 3. Identify use of Complementary or Alternative therapy. 4. Evaluate outcomes of Complementary or Alternative therapy practices. 5. Provide non-pharmacological measures for pain relief. 6. Identify quackery or unscrupulous practitioners. 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP11 4 CONTENT FOR ALTERNATIVE THERAPIES I. Systems of Health Care – Traditional Chinese Medicine – Native American medicine – Homeopathy II. Mind-Body Therapies – A. Journaling – B. Imagery – C. Meditation III. Manipulative Therapies – D. Massage – E. Tai Chi 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP11 5 CONTENT FOR ALTERNATIVE THERAPIES IV. Biologic Based Therapies – A. Aromatherapy – B. Herbal preparations V. Energy Therapies – Healing touch – Therapeutic touch – Reiki 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP10 6 History of Western Medicine 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP11 7 Ancients -- Myths & Religion – Basis For Medical Practice 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP11 8 History of Western Medicine: Ancient Greece & Rome 3/14/2016 Hippocrates Galen C. Matthews RN, MSN M.Elias RN, MSN SP11 9 History of Western Medicine 3/14/2016 Early Christian era ushers in hospitals and health care similar to established Arab Medicine C. Matthews RN, MSN M.Elias RN, MSN SP11 10 History of Western Medicine Middle Ages – Midwives – Witches – Physicians 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP11 11 History of Western Medicine 3/14/2016 Renaissance C. Matthews RN, MSN M.Elias RN, MSN SP11 12 History of Western Medicine – Lister – Nightingale 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN SP11 13 History of Western Medicine 3/14/2016 20th and 21st Centuries C. Matthews RN, MSN M. Elias RN, MSN SP11 14 Integrative Health Care is A Concept of Coordinated Health Care that Includes ALL the Treatments (Conventional and CAMs) and Health Practices that Your Patient uses in their Life. How do We get our Patients to Tell us about the CAMs they use? Course outcome #1 Unit outcome #1 C. Matthews RN, MSN M. Elias RN, MSN SP11 15 What is Holism? Concept focused on Relationships among all living things. Therapeutic Encounters include: – Enhancing Resistance to Illness – Reducing aggravating behaviors – Stress Management – Goal is Optimal state of Wellness for each unique person Course outcome #1 Unit outcome #1 C. Matthews RN, MSN M. Elias RN, MSN SP11 16 RNs must be familiar with C. A. M. “The 2007 National Health Interview Survey (NHIS), which included a comprehensive survey of CAM use by Americans, showed that approximately 38 percent of adults use CAM.” NCCAM retrieved 3/16/11 from http://nccam.nih.gov/health/whatiscam/ Course outcome #1 Unit outcome #1 C. Matthews RN, MSN M. Elias RN, MSN SP11 17 What is CAM? Complementary modalities (therapies): used in conjunction with conventional medical practice. (Wilkinson, p. 1019) Alternative Modalities(therapies): used instead of traditional care. (Wilkinson, p.1019) Unit outcome #3 C. Matthews RN, MSN M. Elias RN, MSN SP11 18 RN must: 1.Be non-judgmental despite personal opinions 2. Build rapport by showing client respect – if not, he may be afraid to tell about CAM use 3. Understand that C.A.M. can be beneficial, when used correctly 4. Be aware that C.A.M. can be dangerous if it interacts or interferes with conventional treatment Course outcome #1 Unit outcome #1 C. Matthews RN, MSN M. Elias RN, MSN SP11 19 RN must: 5. Be willing to teach the public about the positive and negative information regarding C.A.M. 6. Be aware that use of C.A.M. is popular and increasing and must be included in the history & physical 7. Know that Herbals, in particular, can have significant effect on prescription drugs and body function Course outcome #1,2 Unit outcome #1 C. Matthews RN, MSN M. Elias RN, MSN SP11 20 National Center for Complementary and Alternative Medicine National Institutes of Health established NCCAM. Purposes: – Fund studies evaluating effectiveness of C.A.M. – Advance health professional knowledge re: C.A.M. – Serve as a clearinghouse for information about these therapies 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN SP11 21 NCCAM Domains of C.A.M. Ignatavicius pg 8; Wilkinson p. 1020 National Center for Complementary and Alternative Medicine – 5 categories – Systems of Health Care – Mind-body therapies – Manipulative and body-based therapies – Biologically based therapies – Energy therapies Unit outcome #3 C. Matthews RN, MSN M. Elias RN, MSN SP11 22 Mind-Body Meditation – Stress relief/ reduce anxiety – Relaxation – Reduced levels of lactic acid – Decreased oxygen consumption – Slowed heart rate – Decreased blood pressure – Improved function of immune system – Reduce pain – Relieve symptoms of psoriasis – Improve health (References: Ignativicius; Wilkinson) Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 23 Relaxation Used post-operatively (Ignatavicius, p. 299) Relaxation techniques (Ignatavicius, p. 56-57) – To reduce anxiety, tension & emotional tension which can exacerbate pain Relaxation (Wilkinson Vol 2, p. 967; Vol 1, pg 806-807) Progressive (Wilkinson p. 807) muscle relaxation (PMR) Promoting sleep Can be taught in home setting Nurses can use for reduction of pain & stress. Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 24 Guided Imagery – Distraction when confronting pain, discomfort or fear – Making decisions and altering behavior – Caution: not recommended for emotionally unstable or cognitively impaired client – Helps reduce pain. – Reduction of nausea & vomiting. – Decreasing anxiety – Promoting comfort during cancer treatment – Ignatavicius, 6th ed. p. 9 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 25 Mind - Body Biofeedback Journaling (see Wilkinson text p. 1027) – Provides a vehicle for expressing feelings Hypnosis – Advanced training is NECESSARY Humor – Biochemical Responses? – Physiologic Responses? Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 26 Spiritual Life force beliefs found in most cultures. (Wilkinson, p 1020) Faith healing 3/14/2016 (Wilkinson page 260) C. Matthews RN, MSN M. Elias RN, MSN SP11 27 Spiritual spiritual beliefs – how they affect health Longer life span Predictors of health outcomes Effects on specific diseases – Page 249 Wilkinson Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 28 Prayer Most Widely Used CAM in U.S. (NCCAM, 2004) C.A.M. interventions Prayer (Wilkinson page 257) – For Self – For Others – Healing Prayer Services – Prayer Groups Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 29 Spiritual Intercessory prayer – An organized and regular form of prayer in which someone communicates with his or her higher power on behalf of another who is in need. Healing prayer – Studies showing evidence of improvement Wilkinson, p 259-260 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 30 Spiritual Nurses should expect to work in collaboration with others, particularly ministers, pastors and chaplains, to meet the complex spiritual needs of all patients. Potential problem: the nurse and patient have different views of spirituality – Respect patient’s wishes – If patient asks for spiritual intervention that is inconsistent with the nurse’s beliefs, seek assistance from another nurse or chaplain. Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 31 Manipulative and body-based methods Movement & exercise – Strengthens circulatory & respiratory function – Endorphins – Helps regulate metabolism – Enhances Immune system Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 32 Manipulative and Body-based Therapies Yoga – “life forces in correct balance and flow – Concentration, strength, flexibility, symbolic movements – Breathing, movement & posture Tai Chi – Promotes the flow of qi or energy throughout the body – Ignatavicius, p. 11 – Reduces sx. of fibromyalgia – Used in cardiac rehab programs, can lower BP Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 33 Other Movement Therapies Dance Therapy Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 34 Chiropractic and Osteopathy Chiropractic – Relationship between Body Structure and Function – Subluxation & Adjustment Osteopaths D.O. vs. M.D. – Includes Osteopathic Manipulation Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 35 Massage – Muscles & Soft Tissues – Benefits of Massage – Contraindications for Massage – Can we (nurses) do Massage? Unit outcomes #1-5 C. Matthews RN, MSN M.Elias RN, MSN SP10 36 Energy – Based Therapies “A group of techniques that work with the body’s energy field by the use of the hands to direct or redirect the energy to enhance balance within the field.” (see Wilkinson page 1033-34) alternativecancer.us/aura.jpg Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 37 Energy – Based Therapies Energy fields www.windsofchange.eu.com/chakra. html http://images.google.com/images?hl=en&q=layers+of+body+energy+field&btnG=Se arch+Images&gbv=2 – Layers – Chakras – Reflexology ‘zones’ http://images.google.com/images?gbv=2&hl=en&q=reflexology+zones&btnG=S earch+Images – Traditional Chinese Medicine – 12 Meridians (Ignatavicius, 6th ed., page 9) – Acupressure ‘meridians’ (Wilkinson figure 40-3 page 1024) – Acupuncture chi/blockages Unit outcomes #1-5 CC. Matthews RN, MSN M. Elias RN, MSN SP11 38 Energy – Based Therapies Therapeutic massage – Precaution – Wilkinson p. 1033 Therapeutic touch – Caution for touch – Ignatavicius 6th ed., page 13 Healing touch Reiki Acupressure Reflexology Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 39 Energy – Based Therapies TT (Therapeutic Touch) – Integral to assessment – Bonding – Communication – Soothing, calming, comfort – orientation Contraindications – When NOT to touch – Unit outcomes #1-5 Ignatavicius pg. 13 C. Matthews RN, MSN M. Elias RN, MSN SP11 40 Reiki Create Energy Balance Patient draws Energy Reiki Masters & Training “Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. It is administered by "laying on hands" and is based on the idea that an unseen "life force energy" flows through us and is what causes us to be alive.” http://www.centurylink.net/search/index.php?q=google&context=www.centurylink.net Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 41 Reflexology/Acupressure Reflexology – Ancient Egypt – Energy Zones Top to Bottom – Pressure Points – What conditions benefit from it? Acupressure – Meridians & Pressure Points Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 42 Acupuncture Derived from traditional Chinese medicine and other countries and alternative systems Qi (chi) Energy travels through 72 Meridians in the body Needles are applied to Acupoints on the Meridians to restore the flow of qi Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 43 Acupuncture – uses for Migraine headache – Ignatavicius, p. 953 Pain and Anesthesia – Ignatavicius p. 57 3/14/2016 C. Matthews RN, MSN M.Elias RN, MSN SP10 44 The dreaded nausea and vomiting which commonly occurs in some patients undergoing chemotherapy and inevitably, with the use of certain classes of agents, can often be worse than the disease itself. Most oncologists have experienced the patients who start vomiting at the thought of their next clinic visit. At the University of Los Angeles (UCLA) School of Medicine, a well-controlled study completed over two Years ago, the authors of the published paper reported significant reduction of nausea and vomiting when pre-treated with. It is now routinely administered before, after and in between chemotherapy treatment sessions for control or nausea and emesis. Such treatments are relatively simple and easily executed in an outpatient setting. Its effectiveness helps in minimizing the use of standard, expensive multidrug anti-nausea regimens with their attendant side effects, given along with the chemotherapeutic agents. Acupuncture in Cancer Treatment by Eugene Mak, MD@ http://www.medicalacupuncture.org/acu_info/articles/cancertreatment.html C. Matthews RN, MSN 3/14/2016 M.Elias RN, MSN SP10 45 Biologically Based Therapies Dietary Therapies Herbs Vitamins Aromatherapy Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 46 Dietary Therapies Nutraceuticals and phytonutrients Protective or healing agents found in plant and animal foods. Free radicals: unstable molecules that alter genetic codes and trigger the development of cancer growth in cells. Antioxidants: react with free radicals, preventing their damaging effects – Sources of antioxidants: vitamin C, betacarotene, vitamin E Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 47 Dietary Therapies Macrobiotic Diets – Yin/ yang of foods – Balanced foods – Foods to avoid: processed and treated foods, red meat, sugar, dairy products, eggs, caffeine – Caution: children and pregnant women may have deficiency in Vitamins D and B12 Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 48 Aromatherapy – Wilkinson page 1030 Essences from oils extracted from plants & flowers. Conditions responsive to aromatherapy: – Stress and anxiety – Muscular and rheumatic pains – Digestive disorders – Skin conditions Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 49 Aromatherapy Can be used for sense of smell, but also as compresses, baths or topical 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN SP11 50 Aromatherapy (Ignativicius, p.12) Lavender – promotes relaxation & sleep Peppermint – stimulation, concentration Sandalwood – ease depression Tea tree – treating MRSA? Chamomile – relaxation Lemon – promotes sleep/ tx for insomnia and/or digestive disorders Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 51 Herbals Cherokee story “…humans were without diseases until the animals created them in retribution for the lack of respect humans had shown them. The plants, however, felt that the animals were much too harsh and volunteered themselves to provide a cure for every disease the animals had created.” Cavendar, p. 55 Course outcome # 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 52 HERBALS – what RN needs to know Major drawback: May delay important diagnosis and treatment. Nursing Intervention: Make certain MD or ARNP is aware of client’s use of herbals. Nursing action: What to assess & instruct preop client regarding herbal therapy. Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 53 HERBALS – what RN needs to know FDA categorized herbals as food and nutritional supplements not as drugs The Dietary Supplement Health & Education Act (DSHEA) of 1994 allowed herbs to be sold as dietary supplements as long as there are no health claims written on labels DSHEA requires no proof of safety or efficacy and sets no standards for products labeled as supplements, i.e. no guarantee the herb is properly prepared Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 54 Commonly used Herbals Ignatavicius page 12 – table 2-3 Know intended uses for each Know Caution & adverse effects of each – Gingko bilboa – Garlic – Echinacea – Ginseng – St. John’s Wort Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 55 Ginko Biloba Reduce Memory Problems, Dementia, Peripheral Vascular Disease Antioxidant & Vasodilatory Properties BUT can cause BLEEDING when used with Anticoagulants Avoid before surgery Also cause Headache, GI Upset Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 56 Garlic Lowers Cholesterol, Lowers BP, Natural Antibiotic, Natural Anti-platelet Agent BUT Causes BLEEDING with other Antiplatelet Drugs Potentiates Anti-diabetic Drugs Avoid before Surgery Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 57 Echinacea Builds Immunity, Helps Wound Healing Use > 8 Weeks & Possible Immune Function Suppression NOT Recommended for People with Immune Diseases Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 58 Ginseng Asian Ginseng- Diabetes, Erectile Dysfunction, “Unclear” Thinking American Ginseng- Diabetes, Prevention of Colds & Flu Siberian Ginseng- Prevent Colds & Flu, reduce Severity of Herpes Simplex type 2 Infections BUT, BUT, BUT, BUT… Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 59 Ginseng and the Big Buts 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN SP11 60 Ginseng & The BIG BUTS Insomnia, Headache, Agitation, GI Upset, Unusual Menstrual Bleeding, Breast Pain, Dizziness, Increase or Decrease BP, Hypoglycemia, Fast/Pounding/Irregular Heartbeat; Severe Allergic Reaction Not with Immune System Disorders, Schizophrenia, Endometriosis, Fibroids NOT FOR Long-term Use Course outcome # 2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 61 St. John’s Wort Ease Mild to Moderate Depression BUT causes Photosensitivity DO NOT use in Major Depression DO NOT use with Other Antidepressants Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 62 Herbals Alert: “Natural” does not always mean harmless. Plants used improperly can be poisonous. Chemicals within herbs can strengthen the immune system, alter blood chemistry, or protect specific organs against disease Caution: some individuals may have allergies Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 63 Herbals Special precaution with pregnant or lactating women and children – should not use without physician’s knowledge Rationale: Unpredictable biologic effects Possible allergies Side effects Herbs have chemical composition Little or no regulation of production/ quality Possible herb/drug or herb/herb interaction Possible delay of treatment is dangerous Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 64 Herbals & the RN Teach about signs of allergic reactions Teach that herbs can be dangerous even if they are not Rx and are “natural” Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 65 Herbals & the RN Always ask about use of herbals when getting medication history “What is the story of why the patient is using the plant medicine or therapy?” – Libster, p. 809 Teach clients to look for products labeled ‘standardized’ – these more likely to have accurate amounts of herb and less likely to have contamination Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 66 Frankincense and Myrrh* medicinal use Have had spiritual significance since ancient times and they also were adopted as medicines for physical ailments. In modern Chinese Materia Medica, these two resins are classified as herbs for vitalizing circulation of blood and are utilized for treating traumatic injury, painful swellings, masses, and other disorders related to stasis syndromes. – MYRRH AND FRANKINCENSE by Subhuti Dharmananda, Ph.D., May 2003 @ http://www.itmonline.org/arts/myrrh.htm Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 *Will not be on the test! 67 Pain in the epigastrum, abdomen, hypochondria, and/or heart due to qi and blood stasis, and stagnation in the viscera and bowels or the channels (jing) and network vessels (luo). Amenorrhea, dysmenorrhea, or postpartum abdominal pain due to blood stasis. Rheumatic complaints due to wind damp causing qi and blood stagnation and stasis in the network vessels. Wounds, scars, and skin inflammation with blood stasis and necrotic tissue. Traumatic injuries with pain, swelling, and redness due to qi stagnation and blood stasis. – 3/14/2016 MYRRH AND FRANKINCENSE by Subhuti Dharmananda, Ph.D., May 2003 @ http://www.itmonline.org/arts/myrrh.htm C. Matthews RN, MSN M. Elias RN, MSN SP11 68 Folk Medicine (Ignatavicius, 6th ed., page 32-33) Learned from experience Passed from generation to generation Preservation of heritage/ culture Some have been scientifically proven (ex. Garlic) Plants/herbs Hot/cold “Evil Eye” (Mal de Ojo) Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 69 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN SP11 70 Folk Medicine Own terminology: (Feel free to ask the meaning) – – – – – – – “high blood” “low blood” “Thick blood” conjure “fall out” gimpy risin’ sugar Weeded breasts “snuffing the mother” “the itch” “thin blood” water dropsy cut pain – Cavendar, 2003 Course outcome #2, 3 & 4 Unit outcomes #1-5 C. Matthews RN, MSN M. Elias RN, MSN SP11 71 Course outcome #2 Unit outcome #6 C. Matthews RN, MSN M. Elias RN, MSN SP11 72 What is Quackery? A pretender Questionable products & services Overpromotion vs fraud Misinformation Useful for some purposes, not others Course outcome #2 Unit outcome #6 C. Matthews RN, MSN M. Elias RN, MSN SP11 73 How to spot Quackery Tell only part of the story Overpromotes nutritional insurance Play on fears about chemicals ‘Everyone needs supplements’ Promise quick, dramatic, miraculous results Anecdotes & testimonials Questionable credentials Claim persecution Promote distrust Take claims directly to the media, not peers Resist peer review Course outcome #2 Unit outcome #6 C. Matthews RN, MSN M. Elias RN, MSN SP11 74 Nurses Educate the Public Teach signals of fraudulent practice Avoid ‘healers’ who: – Promise immediate relief or success – State that their way is the only sure therapy – Refuse to work with other health care providers – Claim to have all the answers – Use testimonials that claim amazing results Course outcome #2 Unit outcome #6 C. Matthews RN, MSN M. Elias RN, MSN SP11 75 One Minute Paper Now is the time to write short answers to: 1. What is something you heard today that is new to you? 2. How do you plan to approach your clients about CAM? 3. List one thing that surprised you. 4. List one thing that reinforced something you already believed. 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN SP11 76 References Cavender, A.(2003) Folk Medicine in Southern Appalachia. The University of North Carolina Press, Chapel Hill, N.C. Ignatavicius, D.D. & Workman, M.L. (2010) MedicalSurgical Nursing. 6th ed. Elsevier Saunders, St. Louis, Missouri. Libster, M.L. (2002) Delmar’s Integrative Herb Guide for Nurses. Delmar Thomson Learning. United States. Wilkinson, J.M. & Treas, L.S. (2011) Fundamentals of nursing, 2nd ed. FA Davis Company, Philadelphia, PA. 3/14/2016 C. Matthews RN, MSN M. Elias RN, MSN SP11 77