Adult Health Nursing Second Years Students Miss: Iman Shaweesh MCH An Najah Univers

1. Miss Iman Shaweesh 1 Adult Health Nursing Second Years Students Miss: Iman Shaweesh �MCH� An Najah University 29,August,2008

2. Miss Iman Shaweesh 2 Pre -operative Nursing Management The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the pt into the operating room table.

3. Miss Iman Shaweesh 3

4. Miss Iman Shaweesh 4 Surgical classifications Diagnostic ( biopsy) Curative ( excision of tumor) Reparative (multiple wound repair) Reconstructive or cosmetic ( mamoplasty) Palliative (relief pain or correct a problem)

5. Miss Iman Shaweesh 5 According to degree of urgency Emergent: require immediate attention without delay. Urgent: require prompt attention within 24-30 hours. Required: requires operation, plan hospital admission within a few wks or months. Elective: should be operated on, failure to have surgery isn�t catastrophic. Optional: the decision rests with the pt, depend on personal preference

6. Miss Iman Shaweesh 6 The patient�s major goals are: Correction or treatment of physical problem Relief of anxiety, worry and depression Acceptance of and preparation for surgical interventions Acceptance and tolerance of preansthetic medications and agents. Avoidance of injury, Nosocomial infections, and complications.

7. Miss Iman Shaweesh 7 The major nursing goals are to: Assist the pt in understanding the physical and psychosocial aspects of the surgical experience Acquaint the pt and his family with the environment, protocol, and expectations as surgery. Teach the pt certain procedures that will help in reducing post operative complications Prepare the physically and psychologically for the operation Collaborative with other members of the health team in coordinating all preoperative procedures.

8. Miss Iman Shaweesh 8 Preparation for surgery1-Informed Consent Criteria for valid Informed consent: Voluntary consent Incompetent pt ( mentally retarded, mentally ill, or comatose) Informed subject Explanation Description of risks and benefits Answer questions about procedure Instructions Pt able to comprehend. (Information written in understandable language.

9. Miss Iman Shaweesh 9 Assessment of health factors that affect pts preoperatively Assessment of Nutritional and fluid status. Respiratory status Cardiovascular status Assessment of hepatic and renal function Assessment of endocrine function Assessment of immunological function Assessment of effects of aging Assessment of prior drug therapy Assessment pts with disabilities

10. Miss Iman Shaweesh 10 Preoperative Nursing Interventions The two goals of preoperative care are: To present the pt in the best possible physical and psychosocial conditions for his operation To initiate every effort that will eliminate or reduce post operative discomforts and complications. Nutrition and fluids: Intestinal preparation Preoperative skin preparation

11. Miss Iman Shaweesh 11 Preoperative Teaching The goal of preoperative teaching is to familiarize the pt with the expected post operative outcomes such as: Facilitation of recuperative period. Attainment of a sense of well-being with minimal fear of the unknown. Decreased need for analgesics Absence of complications Decrease time for hospitalization

12. Miss Iman Shaweesh 12 When and What to teach:  Teaching sessions are combined with various preparations to allow for an easy and timely flow of information and allow time for questions. Teaching should include description of the procedures and include explanations of sensations of the pt�s will experience. The ideal timing or preoperative teaching isn�t on the day of operation, but during the preadmission visit when diagnostic tests are performed.

13. Miss Iman Shaweesh 13 Deep breathing and coughing: Teaching the pt how to promote optimal lung expansion and consequent bloody oxygenation after anesthesia. The goal in promoting coughing is to mobilize secretions so they can be removed .If the pt doesn�t cough effectively, Atelectasis (lung collapse), pneumonia, and other lung complications may occur.

14. Miss Iman Shaweesh 14 Pain Control and Management: Post operatively, medications are administered to relief pain and maintain comfort without increasing the risks for inadequate air exchange.

15. Miss Iman Shaweesh 15 Preoperative psychosocial interventions Reducing preoperative anxiety Cognitive strategies useful for reducing anxiety, music therapy is an easy to administer, inexpensive, noninvasive intervention Decreasing Fears Reflecting Cultural, Spiritual, and Religious Beliefs Include identifying and showing respect for cultural, spiritual, and religious beliefs, such as in pain control, or in blood transfusion.

16. Miss Iman Shaweesh 16 Intra operative Nursing Management Artificial hypotension during operation:

17. Miss Iman Shaweesh 17 Positions on operating table: Comfortable Adequately exposed area Circulation Respiration free Nerves is protected from undue pressure Concern for obese, thin, old pt. Gentle restrains.

18. Miss Iman Shaweesh 18 Intra operative Nursing Positions: Dorsal Recumbent position Trendelenburg position Lithotomy position For kidney operation For chest and abdominothoracic operation Operation on the neck Operation on the skull and brain.

19. Miss Iman Shaweesh 19 Trendelenburg position

20. Miss Iman Shaweesh 20 Dorsal Recumbent position

21. Miss Iman Shaweesh 21 Lithotomy position

22. Miss Iman Shaweesh 22 kidney operation

23. Miss Iman Shaweesh 23 Principles of perioperative asepsis: Preoperative: Preoperative sterilization of surgical materials Placement of the operation room Scrubbing of health team Cleansing the patient�s skin with antiseptic agents Covering the rest of pt�s body with sterile drapes

24. Miss Iman Shaweesh 24 Intraoperative: Asepsis techniques in surgical practice Post operative: Protect the wound from contamination by sterile dressing Heat compresses at site of surgery Antimicrobial agents in infected wounds

25. Miss Iman Shaweesh 25 Environmental control: Meticulous housekeeping in the operating room Sterilizing equipment Laminar air flow system to filter out high percentage of dust and bacteria. Constant surveillance and conscientiousness in carrying out aseptic practice

26. Miss Iman Shaweesh 26 Principles regarding health and operating room attire Clothing Approved Clean Close-fitting cotton dressing Mask No leak air Shouldn�t interfere with breathing or hinder speech or vision Compact and comfortable Avoid forcing expiration Must be changed between operations

27. Miss Iman Shaweesh 27 Headgear Completely cover the hair, clips or dandruff or dust don�t fall in sterile field Shoes Comfortable and supportive Tennis shoes, sandals and boots are not permitted �unsafe and difficult to be cleaned� Must be worn one time only and removed upon leaving the restricted area Gloves

28. Miss Iman Shaweesh 28 Intraoperative Nursing Function: 1- Circulating nurse Manage the operating room Protect the safety an d health needs of the patient Ensuring cleanliness, proper temperature, humidity lighting, safety of equipment, availability of supplies and materials Coordinate the activities other personnel e.g. X-ray Monitor aseptic practice

29. Miss Iman Shaweesh 29 2- Scrub activities Scrubbing of the operation room Setting up the sterile table, preparing sutures and special equipment Assisting the surgeon and the surgical assistance Keeping the time the patient is under anesthesia Check all equipments used in operation are accounted Send specimens to lab

30. Miss Iman Shaweesh 30 Basic rules of surgical asepsis General :Sterility of surface or articles Personnel: Scrubbed personnel remain in the area of the operation . Only a small part of the scrubbed person�s body is considered sterile: from front waist to the shoulder area, forearm and gloves. Drapping: Delivery of sterile supplies Fluids

31. Miss Iman Shaweesh 31 Post operative Nursing Management goal is directed toward the reestablishment of the patient�s physiological equilibrium and the prevention of pain and complications. Removing the patient from the operating table The site of operation should be kept in mind every time. Check positioning of the head ; extension, lying on unaffected site , Check blood pressure; arterial hypotension Remove the wet gown, keep the pt warm

32. Miss Iman Shaweesh 32 Recovery Room:should have Wall and ceiling painted in soft, pleasing colors Indirect lighting Sound proof ceiling Equipment that controls or eliminate noise Isolated quarter for noisy pts. Equipments: ( Breathing aids; oxygen, laryngoscope, tracheostomy set, bronchial instruments, catheters, mechanical ventilators, suction equipments, equipments for circulatory needs blood pressure, parental infusions. Surgical dressing materials, drugs especially emergency drugs.)

33. Miss Iman Shaweesh 33 The pt remains in this room until he has full recovery from the anesthetic agents, stable blood pressure, good air passage, and reasonable degree of consciousness.

34. Miss Iman Shaweesh 34 Immediate post operative nursing care: 1- Respiratory considerations The chief immediate post operative hazards are those of shock and hypoxemia due to respiratory difficulties. Shock can be prevented by administration of intravenous fluids and blood, appropriate drugs

35. Miss Iman Shaweesh 35 Goals of post operative nursing care: 1- To assist the pt in maintaining optimum respiratory function. Positioning Cleaning the airway Promoting lung expansion Rebreathing CO2 2-To assist the cardiovascular status of the pt and correct any deviation. 3-To promote the comfort and safety of the pt Restlessness and discomfort Pain

36. Miss Iman Shaweesh 36 Goals of post operative nursing care 4- To promote hemostats through maintenance of fluid and electrolyte balance, proper nutrition and elimination. 5- To enhance wound healing and avoid or control infection. Nosocomial infection Invaded of skin and mucous membrane by tubes and catheters, by the disease process Effect of surgery and anesthesia reduce resistance of the body

37. Miss Iman Shaweesh 37 Goals of post operative nursing care Organisms in the hospitals Poor hand washing practices This can be reduced by: Continuous health education about infection control policy Deep breathing exercise to prevent accumulation of secretions Sterilization of equipments Antibiotics therapy

38. Miss Iman Shaweesh 38 Goals of post operative nursing care 6-To encourage activity through appropriate exercises, ambulation and Rehabilitation Positioning Ambulation Ambulation increase respiratory exchange Prevent stasis of bronchial secretions Reduce distension Prevent thrombophlebitis Increase rate of wound healing Ambulation done gradually

39. Miss Iman Shaweesh 39 Goals of post operative nursing care Bed exercises. Deep- breathing exercises Arm exercises Hand and finger exercises Foot exercises Exercises to prepare pt for ambulatory activities Abdominal and gluteal contraction exercises

40. Miss Iman Shaweesh 40 Goals of post operative nursing care 7-Psychosocial well-being of the pt and his family. Keep family in bed side for minutes Expression of feelings Participate in self care Attractive grooming 8-Document all phases of nursing process and report data Any slight symptoms that can increase in severity Any progressive and steady change for the worse in the general condition of the pt The pt�s complaints

41. Miss Iman Shaweesh 41 Post operative discomfort 1- Vomiting- Aspiration Insert NGT during surgery Drugs e.g. antiemetics may cause hypotension and respiratory depression Prevent aspiration of vomitus Turn the pt on his side lying position to provide effective drainage from the throat Clean mouth frequently to facilitate breathing

42. Miss Iman Shaweesh 42 2-Abdominal distension Loosing of normal peristalsis within 24-48 hours post operatively is due to trauma in abdomen. he was swallowed mucous and secretions during operation, so he needs to evacuate these things . 3-Thirst. (atropine). 4- Hiccups. It is produced by intermittent spasms of the diaphragm and manifested by a coarse sound. The cause of diaphragmatic spasm is any irritation in the phrenic nerve from its center in the spinal cord.

43. Miss Iman Shaweesh 43 RX.of hiccups Remove of cause by applying NGT Finger pressure on the eyeball for several minutes Induced vomiting Gastric lavage IV injection of atropine Inhalation of CO2

44. Miss Iman Shaweesh 44 Post operative discomfort 6-Constipation It can be treated by simple enema, increased in diet ((Constipation has been described as a constant symptom of complete intestinal obstruction)) ((Cathartic drugs should never be given, except when prescribed by the physician))

45. Miss Iman Shaweesh 45 Post operative discomfort 7-Fecal Impaction This complication as a result of neglect and never should occur. So early ambulation, proper fluid and diet, enemas fairly effective. It accompanied by abdominal discomfort, the pt represent that he needs to defecate, but no relief.

46. Miss Iman Shaweesh 46 Remove the impaction Enema of liquid petrolatum (oil enema) Gloved finger Injection of 30-60cc of H2O2 into the rectum 8- Diarrhea After operation diarrhea is rare. Fecal impaction is the main cause

47. Miss Iman Shaweesh 47 Post operative Complications 1-Shock: Failure to provide adequate cellular oxygenation accompanied by failure to remove the waste products of metabolism. Shock can be occurs with hemorrhage, trauma, burn, infection, and heart disease, and from failure of the three aspects of circulation: the heart pump, peripheral resistance, and blood volume , this cause inadequate blood flow to vital organs or inability of the tissues of these organs to utilize oxygen

48. Miss Iman Shaweesh 48 Pathophysiology: Catecholamines (epinephrine and norepinephrene) are elevated during shock, cause constrict arterioles in the skin, subcutaneous tissue, and kidney; thus dilate arterioles of skeletal muscles and liver. Heart output is increased due to tachycardia and increased myocardial contractibility. The great veins are constricted, increased venous return. Shock stimulates (ACTH) release from the pituitary gland, increased plasma level of glucocorticoids.

49. Miss Iman Shaweesh 49 Glucagons is released and antidiuritic hormone (ADH) released Due to high level of epinephrine, cortisol and glucagons and lower level of insulin stimulate catabolism, decreased oxygen utilization, decreased cardiac output, and insulin insufficiency.

50. Miss Iman Shaweesh 50 Classification of Shock: 1-Hypovolemic shock: is cause by decreased fluid volume due to loss of blood, plasma or water. Fluid volume usually decreased post surgery due to local trauma to tissues and loss of blood and plasma from circulation, which creates a decrease in the circulating blood volume. It characterized by a fall in venous pressure, rise in peripheral resistance and tachycardia.

51. Miss Iman Shaweesh 51 2- Cardiogenic shock: It results from cardiac failure or an interference with heart function, (poor heart pump function, and causing diminished cardiac output) as in MI, arrhythmias, tamponate, pulmonary embolism, epidural or general anesthesia. The signs are increased pressure in the venous bed and an increase in peripheral resistance.

52. Miss Iman Shaweesh 52 3-Neurogenic shock: It occurs as a result of a failure of arterial resistance due to spinal anesthesia, quadriplegia. It characterized by fall in blood pressure, increase heart activity to maintain normal output (stroke volume); this helps in filling the dilated vascular system.

53. Miss Iman Shaweesh 53 4-Septic shock: It results from gram negative septicemia ( infection , peritonitis, etc) The pt exhibit fever, rapid strong pulse, rapid respiration, and normal or slightly decreased blood pressure, flushed , warm, dry skin,, then hypovolemia develops.

54. Miss Iman Shaweesh 54 Clinical manifestation: The classical signs of shock are pallor ,cool , moist skin, rapid breathing, ischemia to eyelids, lips, gums and tongue , weak, thready pulse, small pulse pressure, low blood pressure. Medical and nursing assessment of the pt with shock The goal in initial assessment is to determine the cause of volume loss and the status of the airway

55. Miss Iman Shaweesh 55 Assessment includes the following Respiration: Hyperventilation is the early sign of septic shock. Skin: A cold, pale, moist skin is a sign of vasoconstriction-hypovolmic shock Warm, red skin indicates septic or Neurogenic shock . Pulse and blood pressure: If each 5-15 minutes interval shows a fall in pulse and BP the indicate shock. Urinary output: an indwelling catheter is recommended, a drop in renal artery pressure and flow produces renal artery vasoconstriction and results decrease in filtration and decreased in urinary output. Normal urine output= 50 cc per hour. An output 30cc per minute= oliguria or unuria is a suggestive of cardiac failure.

56. Miss Iman Shaweesh 56 Central venous pressure: It has a value on the volume of blood returning to the heart and the ability of the right heart to propel blood. Average CVP is 5-12 cm water, near zero indicate hypovolemia Arterial blood gases: an arterial pressure of oxygen below 60 mm Hg indicates respiratory acidosis. A PCO2 over 45 mmHg indicated hypoventilation. In shock PCO2 remain normal. Serum lactate: lactate elevation and oxygen dept, the higher the lactate level, the greater the oxygen need.

57. Miss Iman Shaweesh 57 Hematocrite: to determine the kind of fluid in replacement. HCT over 55, plasma and normal saline are given. HCT less than 20, blood is needed Level of consciousness: alert in mild shock, to mental cloudiness immoderate shock. Failure to react or stimuli is irreversible shock.

58. Miss Iman Shaweesh 58 Therapeutic and nursing management of shock: Prevention: Adequate preparation of pt physically. Anticipation of complication Preparation of special emergency equipments e.g. blood studies, BP device, catheters, suction, oxygen, CVP line, IV, defibrillator, solutions. Decrease any operative trauma during surgery Control pain Thermal regulation after surgery Control of blood loss, � if the amount of blood loss exceeds 500 ml, replacement is usually indicated Positioning �dorsal recumbent position to facilitate circulation.

59. Miss Iman Shaweesh 59 Treatment: The pt must kept warm, infusions of Ringer lactate is started, placed in shock position, monitor respiratory and circulatory status. �The basic approach of treatment of shock is to determine its cause and correct it if possible.� 1-Ensure adequacy of the airway. 2- Restore blood volume. .

60. Miss Iman Shaweesh 60 3-Administer vasodilators. Vasopressors are not used for the pts in shock because they have vasoconstriction in the microcirculation which may cause irreversible damage to kidney, lungs, liver, and GIT tissues Vasodilators are given to reduce peripheral resistance, which decrease in turn the work of the heart and increase cardiac output and tissue perfusion. They use Nipride which stimulate cardiac contractibility and lower peripheral resistance

61. Miss Iman Shaweesh 61 4-Provide psychological support and minimize the pt�s energy expenditure. 5-Prevent complications: Avoid peripheral and pulmonary edema due to fluid overload from administering fluid faster than the body can accommodate them.

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63. Miss Iman Shaweesh 63 Hemorrhage Hemorrhage is classified as 1) primary, when it occurs at the time of the operation. 2) Intermediary, it occurs within the first few hours after an operation. 3) Secondary, it occurs some time after the operation, as result of slipping of a ligature because of infection.

64. Miss Iman Shaweesh 64 Clinical manifestations: It depends on the amount of blood lost and the rapidity of its escape. Apprehensive and restless, and moves continually Thirsty, skin is cold, moist, and pale Increase in pulse, fall in temperature, rapid and deep respirations �gasping� Decrease cardiac output Fall of arterial and venous BP and Hb. Palled lips and conjunctiva

65. Miss Iman Shaweesh 65 Management: Positioning in shock position Administer morphine to keep pt quiet Inspect wound for bleeding Giving transfusion of blood and determine the cause. Giving fluids but too rapid to avoid fluid overload

66. Miss Iman Shaweesh 66 3-Femoral Phlebitis or Thrombosis Pathophysiology: It occurs after operation upon lower abdomen or in the course septic diseases e.g. peritonitis or ruptured ulcers. A mild to severe inflammation of the vein in association with a clotting of blood. Complications occurred due to injury to the vein by tight straps or leg holders at the time of operation. Pressure from blanket-roll under the knees, concentration of blood due to blood loss or dehydration. The slowing of blood flow in the extremity leads to lowered metabolism and depression of circulation after operation.

67. Miss Iman Shaweesh 67 The first symptom is pain or cramps in the calf, followed by swelling of the entire legs due to a soft edema that pits easily on pressure, slight fever, chills and perspiration, tenderness. Phlebitis: indicate intravascular clotting without marked inflammation of the veins. The clotting occurs on the calf. The major sign is slight soreness of the calf.

68. Miss Iman Shaweesh 68 Medical and nursing Management: 1) Preventive: Adequate administration of fluids after operation to prevent blood concentration Leg exercises Elastic stockings Early ambulation to prevent stagnation of the blood in the veins of the lower extremity. Low-dose of heparin prophylactically to prevent deep vein thrombosis and major pulmonary embolism Avoid blanket-roll, pillow �rolls or any form of elevation that can constrict vessels under the knees

69. Miss Iman Shaweesh 69 2) Active treatment Ligation of the femoral veins , to prevent pulmonary embolism by eliminating the cause ( thrombi that could become detached from femoral veins and circulate in the blood) Anticoagulant therapy. Heparin given IV by drip method or SC to reduce the coagulability of the blood rapidly Wrapping the legs from the toes to groin with elastic stockings, these prevent swelling and stagnation of venous blood in the legs and to relief pain with leg elevation and legs exercises

70. Miss Iman Shaweesh 70 4- Pulmonary Embolism Emboli: foreign body in the blood stream. Formed by blood clot that becomes dislodged from it�s original site and is carried along in the blood. When it is carried to the heart, it is forced by the blood into the pulmonary artery, where it plugs its artery of the one of its branches. The signs are: Sharp, stabbing pains in the chest. Breathless, cyanotic, and anxious. Pupils dilated, cold perspiration appears. Rapid, irregular pulse.

71. Miss Iman Shaweesh 71 Respiratory Complications 1- Atelectasis: When mucous is plug it closes one of the bronchi, which make collapse of the pulmonary tissue, and massive atelectasis is result. 2- Bronchitis: it occurs within the first 5-6 days. A simple bronchitis is characterized by a cough that produces considerable mucopus, with marked elevation in temperature and pulse. 3- Bronchopneumonia: beside a productive enough, elevation of temperature, with an increase in pulse and the respiratory rate.

72. Miss Iman Shaweesh 72 4- Lobar pneumonia: is less frequent complication after operation. It begins with chill, high temperature pulse, and respiration. Little or no cough, flushed cheeks. 5- Hypostatic Pulmonary Congestion: In old or very weak pts, due to weak heart and vascular system that permit a stagnation of secretions at the base of the lungs. There is elevation of temperature, pulse and respiratory rate, dullness in chest and crackles at the base of the lungs, if it is untreated, it is fatal.

73. Miss Iman Shaweesh 73 Medical and Nursing Management of Pulmonary Complications: 1- Measures to promote the full Aeration of the lung. Ask the pt to have at least 10 deep breaths every hour Use incentive Spiro meter to expand the lungs fully Turning the pt from side to side Suction when needed. Early ambulation

74. Miss Iman Shaweesh 74 1- Indications for specific measures: To treat bronchitis; inhalation of a mist or steam In lobar and bronchopneumonia; take fluids, expectorant and antibiotics drugs For pleurisy; analgesics or cold applications

75. Miss Iman Shaweesh 75 5- Urinary Problems 1- Urinary Retention It occurs after operation in the rectum, the anus and the vagina due to spasm of the bladder sphincter. Nursing management: Allow the pt to sit beside the bed or stand behind the bed to void Sound of running water this relax the spasm of the bladder sphincter Using a warm bedpan to irrigate the perineum

76. Miss Iman Shaweesh 76 A small warm enema Catheterization: this procedure can be delayed after 12-18 hours. Catheterization can be avoided due to: (1) Possibility of infecting the bladder and cause cystitis. (2) Experience that the pt has once catheterization; he will have recurrent. 2- Urinary incontinence It is due to weakness with loss of tone of the bladder sphincter 3- Urinary Infection

77. Miss Iman Shaweesh 77 6- Gastro intestinal Complications Nutritional considerations Surgery in gastro intestinal tract may disturb the normal physiologic processes of the digestion and absorption. Complications vary according to the location and extend of surgery. 1- Intestinal Obstruction It occurs following surgery on the lower abdomen and the pelvis. The symptoms appear after 3-5 days and even after years.

78. Miss Iman Shaweesh 78 The obstruction is due to kinking of loop of intestine from inflammatory adhesions or is involved with peritonitis or irritation of the peritoneal surface. No temperature or pulse elevation, localized pain, distension, vomiting, hiccups proceed the vomiting. Enemas return clean, showing small amount of intestinal content has reached the bowel. Treatment: Constant suction drainage or simple NGT Operation IV fluids

79. Miss Iman Shaweesh 79 7- Wound Complications 1- Hematoma (Hemorrhage) The nurse should know the location of the pt�s incision to inspect the site of operation for bleeding at intervals for the first 24 hours. Any undue amount of bleeding should be reported. 2- Infection (Wound Sepsis) Staphylococcus aureus, E. Coli, Aerobacter aerogenes and pseudomonas aeroginosa. The main important area of prevention lies on aseptic techniques in wound care, cleanliness and environmental disinfection are important. The symptoms appear within 36-48 hours.

80. Miss Iman Shaweesh 80 The temperature and pulse increase, wound become tender, swollen, and warm. Use of warm antiseptic solutions to flush the wound. Take culture at site of operation. Specific antibiotics. 3-Disruption, Evisceration (protrusion of wound center), or Dehiscence (distruption of surgical wound or incision). It results from sutures giving way and from infection, and after marked distention or cough. It occurs because of increasing age and the presence of pulmonary or cardiovascular diseases in abdominal surgical pts.

81. Miss Iman Shaweesh 81 The sign is usually a gush of serosanguineous peritoneal fluid from the wound, rupture of wound, coils of intestine escaping onto the abdominal wall, pain, vomiting. �When disruption of a wound occurs, the surgeon is notified at once. The protruding coils of intestine should be covered with sterile dressing moistures with sterile saline.

82. Miss Iman Shaweesh 82 Thank You

83. Miss Iman Shaweesh 83