Clinical Judgement Model in Healthcare Case Study

Introduction

The postoperative case of Ani Hakavalu presents a complex scenario within the complex field of healthcare that requires careful use of Tanner's Clinical Judgement Model (Wright & Scardaville, 2021). The essay unfolds through the phases of Tanner's model—Noticing, Interpreting, Responding, and Reflecting—examining Ani's clinical presentation, potential differentials, and the ultimate diagnosis of pulmonary embolism (PE). Its analysis outlines a therapeutic plan using the Fonua Model for cardiovascular and respiratory stabilisation, with the reflection emphasising the continuous evaluation and modification of strategies, underscoring the significance of Tanner's model in navigating complex clinical scenarios.

Noticing

Case presentation

Ani Hakavalu, an 82-year-old Tongan woman, recently underwent a total hip joint replacement (THJR) and was presented with rapid breathing three days post-surgery. Ani, a widow, lives with her three grandchildren, son, and daughter-in-law. Even though Ani's surgery recovery is going well, she mentioned having an odd awareness of her breathing. Her medical background includes depression, GERD, moderate COPD, colon cancer, and hypertension. Objective evaluations showed alarming vital signs, including a respiratory rate (RR) of 34 rpm and a significant drop in oxygen saturation (SpO2) to 82% on room air. These findings were in contrast to the consistent reading from the night before. With her family preparing to travel to Australia, she complained of a productively non-productive cough and decreased appetite, which raised questions about her capacity to recover at home. Elevated amounts of lactate, D-dimer, troponin T, and C-reactive protein were detected in blood testing. An ECG revealed left ventricular strain along with sinus tachycardia. Large pulmonary emboli, right heart strain, and thrombus in the pulmonary arteries were discovered by computer tomography pulmonary angiography (CTPA).

Interpretation

Focusing on a preliminary diagnosis of pulmonary embolism (PE), a comprehensive examination of the available data enables us to identify potential diagnoses and rule out differentials. With a huge PE emerging as the most likely cause, Ani Hakavalu's clinical presentation and diagnostic results give a compelling picture of a serious medical condition. The patient's vital signs, which include an elevated respiratory rate of 34 rpm and tachycardia with a heart rate of 125 bpm, particularly the reduction in oxygen saturation (SpO2) from 96% the previous night to a worrying 82%, point to a worsening respiratory state. It is imperative to give this worrying trend serious attention as it strongly implies an acute compromise of the cardiovascular or pulmonary systems. Based on Ani's subjective and systemic evaluation, respiratory distress symptoms are revealed.

She describes having unusual breathing noises, a dry mucous membrane, a non-productive cough with occasional phlegm, decreased appetite, and generalized pain in both legs. The physical examination's objective results of bilateral inspiratory wheeze, greater use of accessory muscles, and intercostal indrawing are consistent with these subjective concerns. The presence of inflammatory markers, such as high WCC and CRP levels, further supports the idea that there was an acute pulmonary incident. The high levels of D-dimer, troponin T, and lactate in diagnostic testing support the clinical suspicion of a systemic response to a thromboembolic event. The electrocardiogram (ECG) showing sinus tachycardia with left ventricular strain emphasises the condition's cardiovascular effects. The CTPA results provide conclusive proof; they indicate a significant burden of pulmonary emboli in major arteries, thrombus in the pulmonary arteries and right heart strain. This thorough imaging validates the results from the lab and clinical settings and clearly illustrates the degree of vascular impairment.

Deriving Possible Diagnoses

The clinical presentation and diagnostic findings of Ani Hakavalu point to five differential diagnoses that could be made, including pneumonia, congestive heart failure (CHF), reactive airway disease (RAD) aggravation, postoperative atelectasis, and thromboembolic events. The tentative diagnosis is a PE.

Pneumonia initially surfaces as a consideration due to respiratory symptoms, but it can be ruled out. Ani does not present with typical symptoms associated with pneumonia, such as fever, which is a hallmark sign of an infectious process affecting the lungs. Pneumonia typically manifests with an acute onset of high fever, productive cough, and chest pain. The nasopharyngeal swab for influenza was reported as negative, ruling out a viral etiology for her respiratory symptoms. Both bacterial and viral agents can cause pneumonia, and a negative influenza test decreases the likelihood of viral pneumonia (Hespanhol & Bárbara, 2020). Ani's respiratory symptoms include rapid breathing, audible breathing sounds, and a cough with minimal sputum. Although these symptoms may be linked to respiratory infections such as pneumonia, the likelihood of pneumonia is reduced due to the unusual features and lack of normal infectious indications. Ani has a history of mild COPD, and the alterations in her respiratory state could be attributed to her recent THJR. These data imply that, rather than being caused by a current respiratory illness, her symptoms might be associated with underlying pulmonary or cardiovascular problems (MacLeod et al., 2021). The CTPA results show signs of right heart strain, thrombus in main pulmonary arteries, and significant burden pulmonary emboli. These results strongly suggest a thromboembolic event, more in line with a PE diagnosis than a pneumonia diagnosis.

When assessing Ani Hakavalu's clinical presentation, symptoms such as tachycardia, high jugular venous pressure (JVP), and reported leg edema were considered, and her family history of acute myocardial infarction (AMI) made congestive heart failure (CHF) a differential diagnosis at first (Ne et al., 2019). However, CHF was excluded from the differential diagnosis due to important reasons. Ani's main complaint was severe respiratory distress with rapid breathing and bilateral inspiratory wheezing, which took the focus away from issues related to the heart. A surgical component was recently added to the THJR, highlighting the necessity of differentiating between underlying medical conditions and surgical consequences. The definitive CTPA results were crucial because they showed indications of right heart strain and massive pulmonary emboli, which provided a strong justification for Ani's acute respiratory impairment. The probability of primary heart dysfunction was substantially reduced in the case of negative chest X-ray data. Redirecting the focus to a thromboembolic event as the primary diagnosis through diagnostic technologies such as CTPA and the dynamic clinical reasoning process highlights the critical role that refined differentials play in customised therapies.

Examination findings of elevated respiratory rate, wheezing, and bilateral inspiratory wheeze in Ani Hakavalu suggest a differential diagnosis of Reactive Airway Disease (RAD) exacerbation. Asthma and chronic obstructive pulmonary disease (COPD), both of which can cause wheezing and respiratory distress, are included under RAD (Walters & Huntley, 2020). Ani's subjective description of unusual breathing noises and her examination-found wheeze are consistent with the hallmarks of a RAD exacerbation. A possible contributing factor to Ani's current symptoms is her medical history of mild COPD, a chronic respiratory ailment that predisposes persons to exacerbations. Ani says she has a mild cough and some unidentifiable phlegm. These signs may point to the worsening of an underlying respiratory condition. However, it can be ruled out as a likely diagnosis using objective evaluations and diagnostic testing. Ani's elevated respiratory rate, wheezing, and bilateral inspiratory wheeze could be consistent with RAD exacerbation (Walters & Huntley, 2020). However, the sudden onset and severity of symptoms, as well as the absence of a significant response to bronchodilators, suggest a more acute and systemic process than a typical RAD exacerbation. Ani's diagnostic blood tests reveal elevated D-dimer, troponin T, and lactate levels, suggesting a systemic issue rather than an isolated respiratory condition like RAD. Additionally, the CTPA results confirm the presence of large pulmonary emboli and right heart strain, providing a more plausible explanation for the symptoms.

After Ani Hakavalu's recent THJR surgery, postoperative atelectasis, the partial or whole collapse of a lung or lobe, is a differential diagnosis. This is a typical consequence following thoracic and abdominal procedures (Östberg et al., 2019). It is caused by suppression of the cough reflex, limited mobility following surgery, and reduced lung function due to anaesthesia. Postoperative atelectasis is not the main diagnosis; nevertheless, it is supported by several characteristics of Ani's presentation and diagnostic results. Her symptoms, which go beyond usual atelectasis, include fast breathing, decreased oxygen saturation, and an accelerated heart rate. Atypical features such as bilateral inspiratory wheeze contrast with the normal breath sounds in atelectasis. Most importantly, a CTPA reveals irregular atelectasis patterns, such as lung thrombosis, right heart strain, and big pulmonary emboli (Hartmann & Screaton, 2020). A thromboembolic event is confirmed by elevated troponin T and D-dimer values, refuting the idea of atelectasis. As a result, the major pulmonary embolism and its related consequences become the primary focus.

Ani Hakavalu's clinical presentation, coupled with diagnostic results, underscores the provisional diagnosis of Pulmonary embolism. The pathophysiology of PE involves the migration of blood clots, typically originating in the deep veins of the legs as deep vein thrombosis (DVT), which then travel to the pulmonary arteries, causing obstruction and compromising pulmonary blood flow. Ani underwent a THJR three days before the onset of symptoms. Post-surgery, patients are at an increased risk of developing DVT due to factors such as reduced mobility and alterations in the coagulation system. Ani's report of strange breathing sounds, increased respiratory rate (RR), and the sensation of breathing fast aligns with the respiratory distress commonly seen in PE (Duffett et al., 2020). The cough and non-productive sputum indicate the body's attempt to clear the airways. Ani's CTPA reveals a large burden of pulmonary emboli within the left main pulmonary artery. Further, a thrombus is identified at the right main pulmonary artery's division, extending throughout both lungs' lobar and segmental arteries (Kaptein et al., 2021). The evidence of right heart strain, as indicated by bowing of the interventricular septum and dilatation of the right heart compared to the left, is consistent with the hemodynamic consequences of a massive PE. Ani's vital signs show a significant decrease in SpO2 from 96% to 82%, elevated respiratory rate (RR) of 34 rpm, and tachycardia with a heart rate (HR) of 125 bpm. Physical examination reveals bilateral inspiratory wheezing, tracheal tugging, and intercostal indrawing, indicating increased breathing work. These findings correlate with the compromised respiratory status seen in PE.

Pathophysiology

Ani Hakavalu's recent THJR surgery has significant implications for her current health. Post-surgery, patients are predisposed to a hypercoagulable state due to a combination of factors, including venous stasis, endothelial injury, and alterations in the coagulation system. The danger of thrombus formation is increased by this increased coagulability, especially in the deep veins of the lower limbs. One of the most frequent effects of decreased mobility following surgery is venous stasis, which is crucial for the start of thrombus formation (Howard, 2019). Due to Ani's restricted mobility following her THJR surgery, deep vein blood flow is sluggish, which fosters the development of clots. Leg muscles contract less when immobile, which prevents the regular pumping action that promotes venous return. Blood collects in the lower limbs, creating the conditions for deep vein thrombosis (DVT) (Chang et al., 2021). Another important component in the pathogenesis of postoperative thromboembolism is endothelial damage. Surgical operations, particularly orthopaedic therapies such as total hip replacement, might harm blood vessel endothelium. The coagulation cascade is triggered by the trauma sustained during surgery, which starts the process of a blood clot forming (Duffett et al., 2020). In treating THJR, endothelial disruption plays a major role in developing thrombus since the surgical site manipulates blood vessels and joint components. The prothrombotic state brought on by surgery is made worse by modifications to the coagulation system. Surgical trauma sets off a complicated cascade of coagulation factors, resulting in an imbalance that promotes the production of clots (Howard, 2019). The release of tissue factor from damaged tissues initiates the extrinsic coagulation pathway, culminating in the generation of thrombin and the conversion of fibrinogen to fibrin. This fibrin meshwork stabilises the developing clot, contributing to thrombus propagation within the deep veins.

In Ani's case, these thrombi, primarily formed in the deep veins of her operated hip, undergo a potentially catastrophic transformation. As blood clots dislodge from the site of origin, they embark on a journey through the venous system. The migration of these emboli to the pulmonary arteries sets in motion a chain of events that culminate in the pathophysiology of PE. The arrival of emboli in the pulmonary arteries heralds the obstruction of blood flow to the lungs. The large burden of emboli within major pulmonary arteries creates a physical barrier, impeding normal blood circulation (Kaptein et al., 2021). This obstruction profoundly affects oxygen exchange, leading to decreased blood oxygenation. As a result, Ani experiences hypoxia, a condition characterised by an insufficient supply of oxygen to meet the body's metabolic demands. Ani experiences respiratory distress due to reduced blood flow to her lungs. She is more likely to wheeze and breathe quickly due to the mismatch between ventilation and perfusion, a defining feature of PE. The right ventricle must work harder to pump blood into the clogged pulmonary arteries due to the obstruction of the pulmonary vasculature. The imaging results on the CTPA show that this increased workload causes the right heart to dilate and the interventricular septum to bow (Zantonelli et al., 2022). Ani's recent THJR surgery, clinical symptoms, and diagnostic results—especially the CTPA results—all come together to provide a clear picture of the complex pathophysiology of PE. Postoperative hypercoagulability sets off a series of events that culminate in embolization, thrombus development, and blockage of pulmonary blood flow. It is essential to comprehend this intricate interaction of variables to direct Ani's therapy and handle the many issues raised by this potentially fatal illness.

Responding

Therapeutic Plan

Given that Ani presented with a large PE, she has to address the underlying thromboembolic event and stabilise her respiratory and cardiovascular conditions right now. The Fonua model's application to Ani Hakavalu's case, who has a huge PE, emphasises the necessity of promptness and teamwork for providing appropriate care (Smith & Stevens, 2022). To combine knowledge and resources, forming a multidisciplinary team, including orthopaedics, pulmonology, and cardiology members, is essential. Priority must be given to setting up prompt measures to stabilise her respiratory and cardiovascular conditions. The team develops customised therapies for Ani's illness by navigating the diagnostic data. The use of evidence-based approaches ensures a thorough and successful therapy approach. For Ani's general health, treating both the acute symptoms and the underlying thromboembolic event is critical.

Ani has to focus on cardiovascular stabilisation due to her increased troponin T and CTPA results, which indicate right heart strain. The treatment strategy calls for starting heparin-based anticoagulant therapy to stop additional clot spread and embolization. Simultaneously, her heart activity must be closely monitored. Based on continuing evaluations, collaboration with cardiology for prospective procedures, such as thrombolytic therapy or, if required, surgical embolectomy, may be considered. It may be necessary to start inotropic assistance to preserve cardiac output and lessen the pressure on the right heart (Jentzer & Hollenberg, 2020). Ani needs immediate respiratory care because of her severe respiratory distress, bilateral inspiratory wheezing, and very low oxygen saturation. With titration based on ongoing pulse oximetry monitoring, oxygen therapy should be started to maintain oxygen saturation above 90%. If her respiratory distress worsens, invasive mechanical or non-invasive positive pressure ventilation (NIPPV) can be considered. It is imperative to monitor breathing sounds, chest wall movement, and respiratory rate continuously (Shi & De Luca, 2019). Working together with pulmonology is essential to maximising respiratory care, which includes corticosteroids and bronchodilators for possible worsening of underlying reactive airway disease.

The primary issue lies in the massive burden of pulmonary emboli compromising Ani's pulmonary vasculature. The therapeutic plan involves the immediate administration of therapeutic-dose anticoagulation with unfractionated heparin (Graif et al., 2020). Monitoring activated partial thromboplastin time (aPTT) ensures therapeutic anticoagulation. Consultation with interventional radiology or vascular surgery to consider inferior vena cava (IVC) filter placement to prevent further embolization may be warranted (Jaramillo & Burnett, 2023). Long-term anticoagulation with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) will be initiated upon confirmation of the diagnosis and stabilisation ( Akpan & Hunt, 2023). The use of anticoagulation poses the potential problem of bleeding, given Ani's recent surgical history and advanced age. Therefore, regular monitoring of haemoglobin, hematocrit, and signs of bleeding (e.g., melena, hematuria) is crucial. In case of overt bleeding or a significant drop in haemoglobin, reversal agents such as protamine sulphate for heparin or specific antidotes for DOACs should be readily available (Piran & Schulman, 2019). A multidisciplinary discussion, including haematology and anesthesiology, can guide the choice and management of anticoagulation to minimise bleeding risks while ensuring effective thromboprophylaxis. Throughout the therapeutic process, close communication with the orthopaedic team is vital. Ani's recent THJR surgery is a significant factor contributing to her hypercoagulable state. Collaborative decision-making regarding the continuation or modification of postoperative thromboprophylaxis is necessary to balance the risk of bleeding and recurrent thromboembolism(Lester et al., 2023). The therapeutic plan will be modified by routine reevaluations of Ani's clinical state obtained from imaging scans, laboratory testing, and physical examinations. Ani's treatment will be approached holistically and patient-centred thanks to the multidisciplinary team's constant communication and cooperation between nurses, respiratory therapists, and physical therapists.

Reflection

I used Tanner's Clinical Judgement Model as a framework to direct my nursing interventions and decision-making procedures when handling Ani Hakavalu's case. The six phases of Tanner's Clinical Judgement Model are Noticing, Interpreting, Responding, Reflecting, Reasoning, and Metacognition. It provides a structured framework that helps nurses navigate these steps. These phases improve a nurse's capacity to decide quickly and intelligently in challenging clinical situations when used in concert (Connor et al., 2022). When I consider this strategy's success, the model was rather helpful in methodically resolving Ani's PE. I used Tanner's paradigm by identifying the relevance of Ani's altered vital signs, decreased oxygen saturation, and fast breathing. Observation spurred additional research, which resulted in the diagnosis of probable respiratory distress. During the reacting phase, I took quick action to treat Ani's worsening respiratory condition. To combat hypoxemia, oxygen therapy was started, and vital signs were constantly watched. Developing a fast and efficient reaction plan required close coordination with cardiology and pulmonology, among other medical specialists. Utilising the ABCDE (Airway, Breathing, Circulation, Disability, Exposure), the method was consistent with Tanner's emphasis on prioritising patients' needs. I continuously evaluated my success during the reflection phase and modified my techniques as necessary. It was essential to regularly reevaluate Ani's clinical status to make sure the selected therapies were producing the intended results. To make adjustments based on ongoing assessments, this reflective process entailed critically assessing whether the original replies aligned with the changing clinical picture. Tanner's model promotes critical thinking and self-awareness in reasoning and metacognition among nurses (Wright & Scardaville, 2021). Continuous reasoning was required in Ani's case to assess evidence, determine possible diagnoses, and rule out differentials. I was driven by metacognition to think about how my prejudices, experiences, and presumptions can affect the therapeutic decisions I make. This self-awareness was especially useful when negotiating Ani's complicated medical background and possible side effects.

Effectiveness of the Intervention

Tanner's Clinical Judgement Model was useful for handling Ani Hakavalu's complicated situation. The model's systematic approach made providing patients with organised, all-encompassing care easier (Wright & Scardaville, 2021). Through identifying and assessing Ani's declining respiratory condition and promptly implementing remedies, the model offered a transparent structure for making informed decisions. The model's strength became especially apparent when it was stressed how important it was to continue reflecting. This made it possible to continuously evaluate the success of the therapies and modify the care plan in light of the changing clinical situation. Tanner's model's cyclical structure ensured that modifications were made in response to new information, which helped create a care plan that was patient-centred and constantly changing (Benner, 2019). Furthermore, the model's emphasis on interdisciplinary cooperation was very important to Ani's administration. Ani's complicated medical problems were met with a unified and well-coordinated response thanks to the systematic approach that enabled efficient contact with cardiology, pulmonology, and other medical specialists.

My learning

The encounter reaffirmed the value of organised, systematic techniques in therapeutic settings. Tanner's paradigm was invaluable for improving my clinical judgement and thinking. It emphasised how important it is to continuously assess the effectiveness of interventions and modify them in light of the changing circumstances of patients. Moreover, the example underscored the importance of multidisciplinary cooperation in handling intricate health matters. To give Ani the best treatment possible, good coordination and communication with other medical specialists were essential. The necessity to continuously review and modify interventions in light of new information and patient feedback became apparent. Tanner's Clinical Judgement Model, thus, offered a systematic framework for clinical reasoning, guaranteeing a comprehensive and patient-centred approach, and it was crucial in resolving Ani Hakavalu's challenging clinical predicament.

Conclusion

An array of differential diagnoses, including postoperative atelectasis, pneumonia, congestive heart failure, worsening of reactive airway disease, and thromboembolic events, were found in Ani Hakavalu's case. CTPA findings, high D-dimer, and elevated troponin T levels confirmed the ultimate diagnosis of major PE. The Fonua Model-based treatment strategy included respiratory assistance, anticoagulation, and constant observation. The comprehensive strategy that guarantees Ani's treatment is in line with changing clinical dynamics and emphasises the value of structured clinical reasoning is underlined by reflection on the application of Tanner's Clinical Judgement Model.

References

Akpan, I., & Hunt, B. J. (2023). How I approach the prevention and treatment of thrombotic complications in hospitalized patients. Blood, 142(9), 769–776. https://doi.org/10.1182/blood.2021014835

Benner, P. (2019). Skill acquisition and clinical judgement in nursing practice. Practice Wisdom, 225–240. https://doi.org/10.1163/9789004410497_019

Chang, W., Wang, B., Li, Q., Zhang, Y., & Xie, W. (2021). Study on the risk factors of preoperative Deep Vein Thrombosis (DVT) in patients with lower extremity fracture. Clinical and Applied Thrombosis/Hemostasis, 27, 107602962110029. https://doi.org/10.1177/10760296211002900

Connor, J., Flenady, T., Massey, D., & Dwyer, T. (2022). Clinical judgement in nursing – An evolutionary concept analysis. Journal of Clinical Nursing, 32(13-14). https://doi.org/10.1111/jocn.16469

Duffett, L., Castellucci, L. A., & Forgie, M. A. (2020). Pulmonary embolism: update on management and controversies. BMJ, 370. https://doi.org/10.1136/bmj.m2177

Graif, A., Kimbiris, G., Grilli, C. J., Agriantonis, D. J., Putnam, S. G., & Leung, D. A. (2020). Safety of therapeutic anticoagulation with low-molecular-weight heparin or unfractionated heparin infusion during catheter-directed thrombolysis for acute pulmonary embolism. Journal of Vascular and Interventional Radiology, 31(4), 537–543. https://doi.org/10.1016/j.jvir.2019.12.003

Hartmann, I. J., & Screaton, N. J. (2020). Pulmonary circulation and pulmonary thromboembolism. Grainger & Allison's Diagnostic Radiology, 2 Volume Set E-Book, 397.

Hespanhol, V., & Bárbara, C. (2020). Pneumonia mortality, comorbidities matter? Pulmonology, 26(3), 123–129. https://doi.org/10.1016/j.pulmoe.2019.10.003

Howard, L. (2019). Acute pulmonary embolism. Clinical Medicine, 19(3), 243–247. https://doi.org/10.7861/clinmedicine.19-3-247

Jaramillo, V. J., & Burnett, A. (2023). Anticoagulation therapy for Pulmonary Embolism (PE). Springer EBooks, 1–30. https://doi.org/10.1007/978-3-030-70904-4_37-1

Jentzer, J. C., & Hollenberg, S. M. (2020). Vasopressor and inotrope therapy in cardiac critical care. Journal of Intensive Care Medicine, 088506662091763. https://doi.org/10.1177/0885066620917630

Kaptein, F. H. J., Kroft, L. J. M., Hammerschlag, G., Ninaber, M. K., Bauer, M. P., Huisman, M. V., & Klok, F. A. (2021). Pulmonary infarction in acute pulmonary embolism. Thrombosis Research, 202, 162–169. https://doi.org/10.1016/j.thromres.2021.03.022

Lester, W., Walker, N., Bhatia, K., Etienne Ciantar, Banerjee, A., Trinder, J., Anderson, J., Hodson, K., Swan, L., Bradbury, C., Webster, J., & Tower, C. (2023). British Society for Haematology guideline for anticoagulant management of pregnant individuals with mechanical heart valves. British Journal of Haematology. https://doi.org/10.1111/bjh.18781

MacLeod, M., Papi, A., Contoli, M., Beghé, B., Celli, B. R., Wedzicha, J. A., & Fabbri, L. M. (2021). Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention and disease impact. Respirology, 26(6), 532–551. https://doi.org/10.1111/resp.14041

Ne, J. Y. A., Chow, V., Kritharides, L., & Ng, A. C. C. (2019). Predictors for congestive heart failure hospitalization or death following acute pulmonary embolism: A population-linkage study. International Journal of Cardiology, 278, 162–166. https://doi.org/10.1016/j.ijcard.2018.12.063

Östberg, E., Thorisson, A., Enlund, M., Zetterström, H., Hedenstierna, G., & Edmark, L. (2019). Positive end-expiratory pressure and postoperative atelectasis. Anesthesiology, 131(4), 809–817. https://doi.org/10.1097/aln.0000000000002764

Piran, S., & Schulman, S. (2019). Treatment of bleeding complications in patients on anticoagulant therapy. Blood, 133(5), 425–435. https://doi.org/10.1182/blood-2018-06-820746

Shi, Y., & De Luca, D. (2019). Continuous positive airway pressure (CPAP) vs noninvasive positive pressure ventilation (NIPPV) vs noninvasive high frequency oscillation ventilation (NHFOV) as post-extubation support in preterm neonates: protocol for an assessor-blinded, multicenter, randomized controlled trial. BMC Pediatrics, 19(1). https://doi.org/10.1186/s12887-019-1625-1

Smith, Q., & Stevens, T. (2022). Māori Health Review: Oranga Tamariki and the Well Child Tamariki Ora review. New Zealand Medical Student Journal, (34), 41-43.‌https://nzmsj.scholasticahq.com/article/36705.pdf

Walters, G. I., & Huntley, C. C. (2020). Updated review of reported cases of reactive airways dysfunction syndrome. Occupational Medicine, 70(7), 490–495. https://doi.org/10.1093/occmed/kqaa133

Wright, J., & Scardaville, D. (2021). A nursing residency program: A window into clinical judgement and clinical decision making. Nurse Education in Practice, 50, 102931. https://doi.org/10.1016/j.nepr.2020.102931

Zantonelli, G., Cozzi, D., Bindi, A., Cavigli, E., Moroni, C., Luvarà, S., Grazzini, G., Danti, G., Granata, V., & Miele, V. (2022). Acute pulmonary embolism: Prognostic role of Computed Tomography Pulmonary Angiography (CTPA). Tomography, 8(1), 529–539. https://doi.org/10.3390/tomography8010042 ‌

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