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Understanding the meaning of patient behavior accepting accountability for what she does and is influenced by the nurse’s perceptions discount 30 gm v-gel free shipping herbals dario bottineau nd, for the outcomes of her action order 30 gm v-gel free shipping himalaya herbals wiki. It may be validated then discount v-gel 30 gm free shipping herbs lung cancer, is deliberate action that is mutually under- through communication between nurse and pa- stood and agreed upon and that is both patient- tient purchase 30 gm v-gel with visa herbals to boost metabolism. Patients experience distress when they directed and nurse-directed (Wiedenbach, cannot cope with unmet needs. The realities are the aspects of the immediate nurs- ior to discover distress and meaning. Nurse-patient interactions are unique, complex, achieves through what she does (Wiedenbach, and dynamic processes. Professional nurses function in an independent • The Agent, who is the nurse supplying the role from physicians and other health-care nursing action; providers. Keep the body clean and well groomed and protect the integument While working on the 1955 revision of the Textbook 9. Avoid dangers in the environment and avoid of the Principles and Practice of Nursing, Henderson injuring others focused on the need to be clear about the function 10. She opened chapter one with the fol- tions, needs, fears, or opinions lowing question: What is nursing and what is the 11. Henderson believed this question was complishment fundamental to anyone choosing to pursue the 13. Learn, discover, or satisfy the curiosity that leads to normal development and health and Her often-quoted definition of nursing first ap- use the available health facilities. It is likewise the Applications unique contribution of nursing to help people be in- dependent of such assistance as soon as possible. She believed the definitions of the day were too general and failed to “The practice of clinical nursing is goal differentiate nurses from other members of the directed, deliberately carried out and health team, which led to the following questions: patient centered. Based on Henderson’s definition, and after coin- This model and detailed charts were later edited ing the term “basic nursing care,” Henderson iden- and published in Clinical Nursing: A Helping Art tified 14 components of basic nursing care that (Wiedenbach, 1964). Eat and drink adequately may be envisioned as a set of concentric circles, with the experiencing individual in the circle at its core. Move and maintain desirable postures tion of the individual’s experienced need for help, 5. Select suitable clothes—dress and undress help provided fulfilled its purpose, fills the circle adja- 7. The next circle holds the essential range by adjusting clothing and modifying the concomitants of direct service: coordination, i. Her sister, she added, had hemorrhaged and almost lost her life the day after she had her baby two years ago. The nurse expressed her understanding of the mother’s fear, but then encouraged her to compare her current experi- ence with that of her sister. She believed that this was necessary to understand the theory that underlies the “nurse’s way of nursing. Reprinted with permission from the Wiedenbach Reading what context she did what she did” (Wiedenbach, Room (1962),Yale University School of Nursing. Realizing her early efforts to link theory, practice, and merit, and to include these consultation, i. The nonprofessional groups concerned with the individ- opportunity you have to do this is exciting! The content of the fourth circle repre- is rewarding, for, by helping nurses to uncover the sents activities which are essential to the ultimate theory that underlies their practice, you are paving well-being of the experiencing individual, but only the way for them to render a finer quality of service to indirectly related to him: nursing education, nursing the patient, and to gain a deepened sense of fulfill- administration and nursing organizations. This has been known as the first theory of The focus of Practice is the experiencing individual, nursing process and has been widely used in nurs- i. For example, a mother had a red vaginal dis- work to be a theoretical framework for the practice charge on her first postpartum day. The doctor had of professional nursing, emphasizing the essential- recognized it as lochi, a normal concomitant of the ity of the nurse-patient relationship. Orlando’s the- phenomenon of involution, and had left an order for oretical work reveals and bears witness to the her to be up and move about. During the Furthermore, Henderson believed that func- 1960s, several studies were published that explored tions pertaining to patient care could be catego- nursing practice issues. She believed that tients’ complaints of pain (Barron, 1966; Bochnak, limiting nursing activities to “nursing care” was a 1963), incidence of post-operative vomiting useful method of conserving professional nurse (Dumas & Leonard, 1963), patient admission power (Harmer & Henderson, 1955). She defined processes (Elms & Leonard, 1966), nurses’ re- non-nursing functions as those that are not a sponses to expressed patient needs (Gowan & service to the person (mind and body) (Harmer & Morris, 1964), and the effects of patient assistance Henderson, 1955). For Henderson, examples of with planning nursing procedure administration non-nursing functions included ordering supplies, (Tryson, (1963). Inherent in this the practice of assigning patients to lesser trained theory is a strong statement: What transpires be- workers on the basis of complexity level. For tween the patient and the nurse is of the highest Henderson,“all ‘nursing care’. The true worth of her nursing theory is that plex because it involves constant adaptation of pro- it clearly states what nursing is or should be today. It is the nurse’s fits that modern technology and modern health role, according to Henderson, “to ‘get inside the care bring—and there are many—we need to pause patient’s skin’ and supplement his strength, will or and ask the question “What is at risk in health care knowledge according to his needs” (Harmer & today”? Conceptualizing the nurse reconsideration of the value of Orlando’s theory as a substitute for the patient’s lack of necessary as perhaps the critical link for enhancing relation- will, strength, or knowledge to attain good health ships between nursing and patient today (Rittman, and to complete or make the patient whole, high- 2001). Despite pendently initiates and controls activities related to Henderson’s belief that it was difficult to promote a basic nursing care. Relating the conceptualization universal definition of nursing, Basic Principles of of basic care components with the unique func- Nursing Care (Henderson, 1960) became an inter- tions of nursing provided the initial groundwork national sensation. To date, it has been published for introducing the concept of independent nurs- in 29 languages and is referred to as the twentieth- ing practice. In her 1966 publication, The Nature of century equivalent of Florence Nightingale’s Notes Nursing, Henderson stated: “It is my contention on Nursing. After visiting countries worldwide, she that the nurse is, and should be legally, an inde- concluded that nursing varied from country to pendent practitioner and able to make independent country and that rigorous attempts to define it have judgments as long as he, or she, is not diagnosing, been unsuccessful, leaving the “nature of nursing” prescribing treatment for disease, or making a largely an unanswered question (Henderson, 1991). She was one of the first nurses to and responded to the question “What is nurs- articulate that nursing had a unique function yield- ing? In writing reflections on the nature of person, not object, and that the relationship nursing, Henderson (1966) states that her concept of nurse and patient is valuable to all. The effects varied nursing approaches Henderson has been heralded as the greatest advo- have on patients’ complaints of pain. The effect of an automatic and deliber- completion of her revised text in 1955, Henderson ative process of nursing activity on the relief of patients’ pain: moved to Yale University. The effects of nursing ap- 1950s there was an increasing interest on the part of proaches during admission.

Flumazenil’s effect is far shorter than benzodiazepines (half-life under one hour (Armstrong et al generic v-gel 30gm overnight delivery jeevan herbals review. Opiates Most opiates have sedative effects; as analgesia is usually necessary buy discount v-gel 30gm lotus herbals 3 in 1 matte review, this ‘side effect’ can be beneficial cheap v-gel 30gm on-line herbals soaps, provided it is remembered when assessing sedation v-gel 30gm sale goyal herbals private limited. Opiates may become Sedation 51 the most important part of sedative regimes (Bion & Oh 1997). Morphine remains one of the most powerful opiates, but newer drugs, such as fentanyl, achieve rapid sedation with strong respiratory depression (which facilitates ventilation). Propofol Propofol’s lipid emulsion facilitates transfer across the blood-brain barrier, achieving rapid sedation. Inactivity of metabolites (Sherry 1997) and rapid redistribution into fatty tissue (Eddleston et al. Widely used for short- term sedation, Propofol is relatively expensive and so some units restrict use to circumstances where sedation is planned to last less than one day. Propofol depresses cerebral metabolism, thus reducing both cerebral oxygen consumption and intracranial pressure (Viney 1996). A number of disadvantages have been reported with propofol: ■ bradycardia from resetting of carotid receptors (Sherry 1997) ■ hypotension from resetting of baroreceptors, sympathetic inhibition and increased venous capacitance (Robinson et al. Use of any drug or equipment beyond a manufacturer’s licence places the onus of legal liability on the users (see Chapter 45). Since propofol does not have any analgesic effect, concurrent analgesia should be given. Intensive care nursing 52 Bolus sedation The introduction of shorter-acting sedatives together with the improvement of infusion pump technology has largely replaced the use of bolus sedation with continuous infusions. Like analgesia, bolus sedation can cause fluctuations between under- and over- sedation (Shelly 1998). Where sedative effects are prolonged, constant infusion can result in over-sedation (Shelly 1998). The lighter levels of sedation now preferred create relatively narrow margins between over-sedation and under-sedation. Over-sedation is arguably inhumane, depriving patients of life awareness, but it also causes respiratory and cardiovascular depression (compromising tissue perfusion) and so it potentially prolongs recovery. Drugs also increase the costs of patient care, placing further burdens on (usually) stretched unit budgets. Thus unnecessary drugs are psychologically, physiologically and financially undesirable. Increased protein (muscle) breakdown from stress-induced hypermetabolism (see Chapter 3) prolongs ventilatory weaning and (eventual) ambulation, thus increasing the risk of later complications such as pneumonia and thromboses. However, sedation is difficult to measure, both because the needs of patients vary (Shelly 1998) and because of the discrepancies between different assessors (Westcott 1995). Gently brushing the tips of eyelashes can usefully identify if someone is sedated deeply enough to tolerate traumatic interventions (e. However, a more precise measurement is desirable for evidence-based nursing assessment and the search for precision has created various sedation scales, most developed in this country, many initially for drugs research. Some scales, such as Bion and Ledingham, are too complex and time-consuming for routine use, and few have been tested for reliability (Olleveant et al. However most lists are relatively simple, if potentially subjective; Shelly (1998) suggests that the choice between tools is less important than using one to ensure regular assessment. Reliable assessment necessitates familiarity and confidence with whatever is used, and so limiting the number of tools used on one unit promotes reliable assessment. However, many scales necessitate inflicting pain and so, for regular assessment, observation- orientated tools may be more appropriate. Many scales are known both by their developer’s names and the place where they were developed. Sedation 53 Paralysis, whether from paralysing agents or pathology, prevents patients expressing awareness so that infusions of any paralysing agents should be stopped long enough before sedation assessment to ensure they will not influence the result. Achieving optimum sedation is a humanitarian necessity; professional autonomy and accountability make each nurse responsible for ensuring their patients are appropriately (i. The only reasonable way to ensure patients are adequately sedated is by objective assessment. The Ramsay scale Originally designed for drugs research rather than clinical use, this scale (see Table 6. Bion suggests that patients should be observed for 10–15 minutes before assessment (Olleveant et al. Intensive care nursing 54 The Cohen and Kelly scale Like the Ramsay scale, this scale (see Table 6. Being based on a tried and trusted neurological assessment tool, it has proved reliable. The scoring system is more complex than Ramsay and Ramsay-like scales, which can make it time-consuming, but makes it more comprehensive. The last two categories (paralysed, asleep) were added to the initial four-point scale following comments by nursing staff; the fourth category (roused by tracheal suction) was also added (see Table 6. However, the subjectivity of Ramsay is replaced by descriptions of each level, enabling greater objectivity (descriptions are omitted from Table 6. They claim this modification is more reliable, although potential researcher bias necessitates further objective measurement to support their claim. The Dutch unit does not normally use sedation, arguing that very sick patients are naturally sedated, and that chemical sedation overpowers useful compensatory mechanisms. Monger’s (1995) article makes passing mention of the use of physical restraints to maintain safety. The choice between chemical (sedation) and physical restraint is an ethical dilemma with no absolute answer. As with Monger’s awake patients, this allows response to both verbal and physical stimuli (Hudak et al. Ensuring amnesia while allowing consciousness implies that this is merely an extension of lighter sedation. While amnesia is arguably beneficial from humanitarian perspectives, nurses should ensure that patients are not exposed to unnecessary pain (physical or psychological), however soon that pain may be forgotten. Paediatric sedation As with analgesia, usually children have traditionally received little sedation, presumably for similar (unfounded) reasons (see Chapter 7). Unless drugs are specifically contraindicated for children, approaches to sedation should be similar: humanitarian arguments for sedating adults should apply equally to children. However, the higher metabolic rate of children may cause more rapid clearance, necessitating larger doses; Sherry (1997) suggests that children may need up to 50 per cent more sedation (relative to weight) than adults. Neuromuscular blockade Blocking release of acetylcholine (a neurotransmitter) at the neuromuscular junction causes skeletal (but not smooth) muscle relaxation. Paralysing agents cannot cross the blood-brain barrier, so have no sedative or analgesic effects. Once the standard conjunct therapy with sedation, the use of paralysing agents (also called muscle relaxants) showed a similar reversal between the three studies cited at the start of this chapter. The routine use of paralysing agents fell from nearly all units in Merriman’s 1981 study to only 16 per cent regularly using it by 1987 (Bion & Ledingham 1987), with little change (15 per Intensive care nursing 58 cent) by Reeve and Wallace’s 1991 study. The reasons for reduced use of paralysis reflect those for reduced use of chemical sedatives.

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Which of the following medications 30 gm v-gel overnight delivery biotique herbals, in addition to a rescue β2-agonist inhaler buy v-gel 30 gm with amex lotus herbals quincenourish review, should be pre- scribed for outpatient use? Upon physical examination cheap v-gel 30gm fast delivery herbs nutrition, the patient has clear breath sounds bilaterally and no signs of trauma generic 30 gm v-gel himalaya herbals 100 tabletas. Given this clinical presentation, what initial antibiotic coverage is most appropriate for this patient? The patient is endotracheally intubated, given a 2-L bolus of normal saline, and started on antibiotics. You see a friend that accompanied the patient to the hospital and ask him some questions. What is the most likely organism that is responsible for the patient’s presentation? Upon physical examination, there are decreased breath sounds on the right as compared to the left. A chest radiograph indicates blunting of the right costophrenic angle with a fluid line. Given this patient’s history, which of the following most likely describes his effusion? Upon physical examination, the patient appears to be in mild distress with audible wheezing. She is able to speak in partial sen- tences and states that she occasionally uses an inhaler. Given this patient’s history and physical examination, which of the following measures should be taken next? If pharyngeal or laryngeal structures become involved, or there is significant tongue swelling, the patient may begin to compromise their airway and emergent intubation or surgical cricothyroidotomy needs to be performed. All patients need to be on a monitor and should receive supplemental oxygen despite normal oxygen saturation. Heparin is the first-line therapy in this patient and should be administered promptly. Warfarin initially causes a temporary hypercoagulable state because the anticoagulants, protein C and S (inhibited by warfarin), have shorter half-lives compared with the procoagulant vitamin K–dependent proteins that warfarin also inhibits. Classically, it presents with a productive cough with currant jelly sputum, fever, general malaise, and an overall toxic appearance. A dense lobar infiltrate with a bulging fissure appearance on a chest radiograph is often described. Streptococcus pneumoniae (a) is the most common etiology in community- acquired pneumonia among adults. Mycoplasma pneumoniae (c) is a common cause of community-acquired pneumonia in patients under the age of 40. Legionella pneumophila (d) is an intracellular organism that lives in aquatic environments and is not transmitted from person to person. It is a pleomorphic gram-negative rod that can be encapsulated and identified as various serotypes, with type b as the most commonly causing bacteremia. Mild tachycardia, decreased breath sounds to auscultation, or hyperresonance to percussion are the most common findings. It typically occurs in healthy young men of taller than average stature without a pre- cipitating factor. Mitral valve prolapse and Marfan syndrome are also asso- ciated with pneumothoraces. Although suggested by this patient’s symptoms, the diagnosis of pneumothorax is generally made with a chest radiograph. The classic sign is the appearance of a thin, vis- ceral, pleural line lying parallel to the chest wall, separated by a radiolucent band that is devoid of lung markings. If clinical suspicion is high with a negative initial chest x-ray, inspiratory and expiratory films, or a lateral decubitus film may be taken to evaluate for lung collapse. A D-dimer (b) is a blood test used as a screening tool in patients who have a low pretest probability for a thromboembolism. If the chest radiograph is unremarkable in this patient, sending a D-dimer may help in the workup of his dyspnea. An upright abdominal x-ray (d) can assess for abdominal perforation, char- acteristically revealing air under the diaphragm. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia. Auscultation of the lungs reveals decreased breath sounds over the infiltrate and the radiograph shows a lobar pattern. Radiograph findings include a necrotizing right-upper lobe infiltrate or abscess with an air-fluid level. Although the patient in the scenario is an alcoholic, S pneumoniae is still the most common cause of community-acquired pneumonia. She is tachycardic, tachypneic, and hypoxic, cardinal signs of cardiovascular distress. The clas- sic triad of dyspnea, pleuritic chest pain, and hemoptysis is uncommon and present in less than 25% of patients. Most patients have constitutional symptoms, in addition to conjunctivitis, pharyngitis, or bullous myringitis. The hallmark of the disease is the disparity between the patient’s clinically benign appearance and the 66 Emergency Medicine extensive radiographic findings. This is a reversible bronchospasm initiated by a variety of environmental factors that produce a narrowing and inflammation of the bronchial airways. The first-line treatment in order to open the airways includes a β2-agonist, which acts to decrease bronchospasm of the smooth muscle. Corticosteroids (a) are an effective measure for decreasing the late inflammatory changes involved in asthma. Magnesium sulfate (b) is also thought to act in a similar manner, but should be initiated in refractory cases of asthma. Epinephrine (c) decreases bronchospasm, but given its clinical side effects should only be administered in patients deemed to be in severe respiratory distress. This example reminds us of the importance of keep- ing the differential diagnosis broad in patients that present with respiratory distress. The other procedures may be done in a timely manner, but do not necessarily need to be performed as the next most critical step. As a result of this mechanism, the substance can be concen- trated in high amounts in the lung parenchyma causing an infiltrative inflammatory process and pneumonitis referred to as “crack lung. Cannabis (a) used in conjunction with inhaled β2-agonists may result in bleb formation and subsequent pneumothorax, but not pneumonitis. Opioids (b), methamphetamine (d), and alcohol (e) may have pulmonary effects through secondary mechanisms, but are not primarily responsible for this type of presentation. A repeat chest x-ray (a) may be performed; however it will be low- yield if the original was performed correctly. Chest thoracostomy (d) involves placing a tube inside the pleural cavity to evacuate the intrapleural air and may be performed if the patient continues to decompensate and if the suspicion for a pneumothorax remains high.

Love and belonging needs: The nurse helps the counseling services safe v-gel 30gm bestlife herbals, community services buy v-gel 30gm with visa herbals and warfarin, skilled husband to cope with his fears and gets him nursing care ready to participate in the birth of his child cheap v-gel 30gm on line herbs de provence walmart. What are the ethnic Multiple Response Questions background and religious affiliation of family mem- 1 effective 30gm v-gel planetary herbals quality. General systems theory: This theory explains health condition; safety and security needs for a breaking whole things into parts and then learn- safe environment for a patient with Alzheimer’s ing how these parts work together in systems. It disease; love and belonging needs related to his includes the relationship between the whole and desire to remain with, and care for, his wife; self- the parts and defines concepts about how the esteem needs based on his pride in taking care of parts will function and behave. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Improved autonomy of nursing: Nursing is in as the adjustment of living matter to other living the process of defining its own independent things and to environmental conditions. The tion is a dynamic or continuously changing development and use of nursing theory provide process that effects change and involves interac- autonomy in the practice of nursing. Horn with informa- heredity, temperament, emotional and physical tion and practical tips for inserting a nasogastric environment, life experiences, and health status. Nursing theories identify and define interrelated the procedure, the nurse could ask for a return concepts specific to nursing and clearly state the demonstration from Ms. Nursing theories must be logical and use orderly able if any problems occur and provide her with the reasoning and identify relations that are appropriate resources. Nursing theories should increase the nursing her ability to take care of her mother. What intellectual, technical, interpersonal, and/or research and should guide and improve practice. After Nightingale established an Technical: ability to provide technical nursing assis- acceptable occupation for educated women and tance based on sound scientific rationales to meet facilitated improved attitudes toward nursing, the learning needs of Ms. Horn the role of the woman as nurse became more Interpersonal: ability to demonstrate empathy and favorably accepted. Educational influences on nursing: The service Ethical/Legal: ability to provide patient education orientation of nursing was the strongest influ- consistent with the nursing code of ethics and ence on nursing practice until the 1950s. Nursing education nasogastric tube feedings, home healthcare services began to focus more on education instead of just if applicable. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Ethical responsiveness: The nurse can decide to ignore his/her superior’s breach of confidence, or 1. Values clarification: Have the mother state the confronting his/her superior, the nurse was able three most important things in her life. Explore to make a positive impact on the hospital envi- her answers with her and find out why she chose ronment. Identify the ethical problem and explore possible, involve the husband and child in deci- solutions to the problem. Acting: Assist the mother to plan new behaviors ing assistance for the patient at a higher level). For example, if superiors and presenting your case in a competent she values her child, she may reduce the number manner. Covering for another nurse who is not perform- colleagues ing her job competently, short-staffing d. Autonomy: Respect the decision-making capacity the role of the nurse in certain situations of autonomous persons (e. Justice: Distribute benefits, risks, and costs fairly rights by being a strong patient advocate. Fidelity: Be faithful to promises you made to the nurse could also check with the drug manufacturer to public to be competent, and be willing to use see if the company has a discount for needy patients. Raines vocalizes the health benefits of taking his entrusted to your care without first seeing to blood pressure medication and lists three reasons for his/her needs). Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Failure to ensure patient safety: Update knowl- Intellectual: ability to integrate ethical principles edge on patient safety and new interventions and use an ethical framework and decision-making to prevent and reduce injury. Improper treatment or performance of Technical: ability to integrate ethical agency to treatment: Use proper techniques when perform- provide the technical nursing assistance necessary ing procedures and follow agency procedures. Failure to monitor and report: Follow physician Interpersonal: ability to advocate for patients whose orders regarding monitoring of patient unless values may be different from personal ones changes in the patient’s condition necessitate a Ethical/Legal: ability to identify and develop the change in the frequency of monitoring; report essential elements of ethical agency, cultivate the need for change to physician. Medication errors and reactions: Listen to that dictate and justify professional conduct patient’s objections regarding medication and 4. Failure to follow agency procedure: Advise the appropriate person of procedures that need to be revised. Equipment misuse: Learn how to operate equip- ment in a safe and appropriate manner. Knowledge of the state (or province) Nurse Prac- tice Act and standard of nursing care where the 1. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. There are increasing numbers of older people liv- attorney may call the first nurse to testify as a fact ing longer with multiple chronic illnesses who witness if he or she has knowledge of the actual are not institutionalized. With more sophisticated technology, people can base testimony on only firsthand knowledge of the be kept alive and comfortable in their own homes. Healthcare consumers demand that services be about facts, the nurses should simply testify, “I do humane and provisions be made for a dignified not remember that. Primary care offices: Make health assessments, ethical/legal competencies are most likely to be assist physician, and provide health education used in this situation? Ambulatory care centers and clinics: A nurse Intellectual: knowledge of law and sources of law practitioner may run these centers, which and ability to identify potential areas of liability usually provide walk-in services and are open at in nursing times other than traditional office hours. Mental health centers: Nurses who work in crisis tance in a competent, legally appropriate manner intervention centers must have strong communi- Interpersonal: ability to work collaboratively with cation and counseling skills and must be other members of the healthcare team and legal thoroughly familiar with community resources department specific to the needs of patients being served. Rehabilitation centers: These centers use a action healthcare team comprising physicians, nurses, 3. What resources might be helpful for the nurses in physical therapists, occupational therapists, and this case? Long-term care centers: Help patients maintain management programs, malpractice arbitration panel function and independence with concern for the Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Provide direct care, supervise others, serve meet the needs of families of patients on hospice as an administrator, and teach. With the trend toward discharging patients earlier, available resources to ensure everyone’s access to hospitals more often focus on the acute care needs safe, quality healthcare of the patient. Along with this focus has come a Ethical/Legal: knowledge of ethical and legal princi- proliferation of services offered by the hospital ples related to patients with terminal illnesses aimed at the outpatient. If the Multiple Response Questions cost of hospitalization is greater than that assigned, 1.