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Chapter 121st Century Maternity and Womens Health NursingCopyright 2016 by Elsevier Inc. All rights reserved.

#Copyright 2016 by Elsevier Inc. All rights reserved.#Copyright 2016 by Elsevier Inc. All rights reserved.Welcome to Maternity and Womens Health Care in Nursing. In the next 8 weeks we will embark on the care of women during pregnancy to their delivery and postpartum care and the care of the newborn and some womens health. We will also discuss the High risk of each area.Copyright 2016 by Elsevier Inc. All rights reserved.1Learning ObjectivesDescribe the scope of maternity and womens health nursing.Evaluate contemporary issues and trends in maternity and womens health care.Examine social concerns in maternity nursing and womens health care.Integrate evidenced-based practice into care plans.Explain risk management and standards of practice in the delivery of nursing care.Discuss legal and ethical issues in perinatal nursing.Examine Healthy People 2020 goals related to maternal and infant care.#Copyright 2016 by Elsevier Inc. All rights reserved.Our Learning objectives are: read the slide.Copyright 2016 by Elsevier Inc. All rights reserved.2What Is Maternity and Womens Health Nursing in the 21st Century?Maternity careWomens health careRole of nurses in womens health careSignificant advances in care

#Copyright 2016 by Elsevier Inc. All rights reserved.#Copyright 2016 by Elsevier Inc. All rights reserved.Maternity nursing encompasses care of childbearing women and their families through all stages of pregnancy and childbirth as well as the first 4 weeks after birth.Maternity nurses teach about pregnancies, the process of labor, birth, and recovery, and parenting skills. They provide care continuity of care throughout the childbearing cycle.Womens health care focus on physical, psychological and social needs of women throughout their lives.These nurses roles are unique to the care of women such as reproductive malignancies and menopause. They have a role in the care of their sociocultural and occupational factors that relate to womens health (such as poverty, rape, incest, family violence, and human tracking).And as stated earlier, providing care for women and their families during the childbearing cycle.Nurses help to make the health care system more responsive to womens needs. They have been critically important in developing strategies to improve the well-being of women and their infants and have led the efforts to implement clinical practice guidelines and to practice using evidence-base approach. Through professional associations, nurses have a voice in setting standards and in influencing health policy by actively participating in the education of the public and of the state and federal legislators. Examples of these organizations are stated in your book.Awesome Advances have been made of the past 150 years. (see the box 1.1) in the care of mothers and their infants. However, there are still serious problems that exist in the U.S related to health and health care of mothers and infants.Some of these are :Lack of access to pre-pregnancy and pregnancy related care for all women and the lack of reproductive health services for adolescents are major concerns.And Sexually transmitted diseases, affect reproduction adversely.Racial and ethnic diversity is increasing in North American. With the highest population European-American, follow by Hispanics, African-American, Asians, American Indians and Alaska natives. Then Hawaiian and other Pacific Islanders. What does this mean to provide care to the diverse cultures and ethnicities we also need and increase in nurses that are diverse in the nursing workforce. (You can see your book for the actual percentages).3Copyright 2016 by Elsevier Inc. All rights reserved.Womens Health DisparitiesEfforts to decrease disparitiesHRSA Health Disparities Collaboratives The National Institutes of Health National Institute of Nursing Research Centers for Disease Control and Prevention (CDC) First Periodic Health Disparities and Inequalities ReportUnited States, 2011 U.S. Department of Health and Human Services HHS Disparities Action Plan

#Copyright 2016 by Elsevier Inc. All rights reserved.Womens Health Disparities- what is being done about this situation? These agencies on national levels are committed to decreasing womens disparities. The HRSA is focusing on how to improve delivery systems of health care for everyone in the U.S who is cared for by a HRSA health care center. Presently more than 900 community centers exist. The National Institute of Nursing Research focusing on improving the health care of minorities and provides funds for research training of minority researchers. CDC- provide the report that you see in 2011 with focus on trends and variation in health disparities and inequalities in some social and health indicators, which provides data that can be use to measure progress in eliminating disparities. The last organization- focus is on providing evidence base programs, integrated approaches, and best practice to reduce disparities.So you can see there is an major push to reduce and eliminate disparities. Copyright 2016 by Elsevier Inc. All rights reserved.4Contemporary Issues and TrendsHealthy People 2020 goalsEliminate preventable disease, disability, injury and premature deathAchieve health equityCreate social and physical environments that promote good health for allPromote healthy development and healthy behaviors across every stage of life#Copyright 2016 by Elsevier Inc. All rights reserved.Health People- Provide science-based 10 year objectives for improving health and preventing disease in the for all Americans. Health People 2020 goals are as stated on this slide. Copyright 2016 by Elsevier Inc. All rights reserved.5Contemporary Issues and Trends (Cont.)Healthy People 2020 goals related to maternal health:Reduce the rate of fetal and infant deathsReduce the rate of maternal mortalityReduce preterm births Reduce cesarean births among low risk women#Copyright 2016 by Elsevier Inc. All rights reserved.They have approx. 1200 objectives and them 33 are related to maternal, infant, and child health. (you can find these listed in the box on pg. 4 box.1-2. The objectives of these are to l. reduce the rate of fetal and infant deaths, 2. reduce the rate of maternal mortality, 3. reduce preterm births, and 4. reduce C/S births among low risk women. Pg. 3And I can say from experience, obstetricians are now practicing where they will not deliver the infant before 36 weeks if there is not a high risk cause. In the past they would deliver women who would complain of not wanting to be pregnant anymore, or wanting to deliver before the 1st of the year. (this would many times call complications with the newborn ending up in the NICU).Copyright 2016 by Elsevier Inc. All rights reserved.6Contemporary Issues and Trends (Cont.)Millennium development goals8 goals to be achieved by 2015Respond to the worlds main development challengesAdopted by 189 nations Goals specific to womens healthPromote gender equality and empower womenReduce child mortalityImprove maternal health#Copyright 2016 by Elsevier Inc. All rights reserved.There is also a Millennium development goals. Goals for3-5 are more specific to women and children. You can review this on the state pages.These 8 Goals are listed in Box 1-3. pg. 4

Copyright 2016 by Elsevier Inc. All rights reserved.7Contemporary Issues and Trends (Cont.)Interprofessional educationClient care will improve when health professionals work together.The interprofessional collaborative practice competency domains include Values/ethics for interprofessional practiceRoles/responsibilitiesInterprofessional communicationTeams and teamwork

#Copyright 2016 by Elsevier Inc. All rights reserved.Interprofessional education consists of faculty and students from 2 or more health professions who create and foster a collaborative learning environment. When this is provided it will provide the clients with overall best of care. For this to happen these 4 domains need to be included.8Copyright 2016 by Elsevier Inc. All rights reserved.Contemporary Issues and Trends (Cont.)Problems with the U.S. health care systemStructure of the health care delivery systemReducing medical errorsHigh cost of health careLimited access to careHealth care reformIn early 2010, President Obama signed into law the Patient Protection and Affordable Care Act (ACA)#Copyright 2016 by Elsevier Inc. All rights reserved.Here are the problems that our health care system faces. The Structure of the health care delivery system- is fragmented, expensive and inaccessible to many clients. Nurses have the opportunity to alter nursing practice, improve the way care is delivered through manage care, integrated delivery systems, and redefined roles. Providing information via internet (e-health) will help the clients use the information is participating in their won care and consult health care providers with a knowledge base previously difficult to access.Reducing Medical Errors- this is the leading cause of death in the U.S. and results in as many as 98,000 deaths per yr. The Agency for Healthcare Research and Quality (AHRQ, 2000) prepare a fact sheet- they came up with a 20 Tips to Help Prevent Medical Errors, for clients and the public. These tips are encouraged to be read so the consumers are knowledgeable of health care and to ask questions of providers, which are Drs, midwives, nurses and pharmacists. ( An example of this would be with a relative of mine who asked the nurse to explain all the pills that she had just placed in the medicine cup without explaining what each one were. The nurse was offended and somewhat upset because she was questioned, however, my relative was right in asking her about the medications).Health Care is expensive- care of a neonate for low-birth weight in the NICU is costly. Nurse mid-wives have help with some of the cost of maternal care, and Nurse practitioners. Limited Access to Care- barriers to access must be removed for pregnancy outcomes and care of children can be improved. The Most significant barrier is finances (inability to pay). 15% of the population is in U.S are uninsured. See your book for other barriers. Pg.5The Health Care Reform is to focus on making insurance affordable, contain costs, strengthen and improve Medicare and Medicaid and reform the insurance market. Copyright 2016 by Elsevier Inc. All rights reserved.9Contemporary Issues and Trends (Cont.)Accountable care organizations (ACOs)Coordinate high-quality careEliminate duplication of servicesPrevent medical errorsHealth literacyE-health literacy#Copyright 2016 by Elsevier Inc. All rights reserved.The Center for Medicare & Medicaid Services (known as CMS) finalized new rules under the Affordable Care Act (known as ACA) to help health care providers and hospitals coordinate care better for Medicare clients through Accountable care organizations. The goal of this organization is for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending. This done by focusing on the 3 areas listed. P. 5 Health literacy- Most of clients education materials are written at too high a level for the average adult. Reading levels have not improved much from the surveys conducted in 2003 where most average adults are not able to read much above a 7-8th grade level. The E-health concept has emerged as individuals use the internet to diagnosis and more than half seek the opinion of a medial professional rather than trying to care for themselves based on information assess.The need for health literacy as a component of culturally and linguistically competent care is urgent.Copyright 2016 by Elsevier Inc. All rights reserved.10Trends in fertility and birth ratesTrends:Fertility rateBirth rateLow birth weight and preterm birthInfant mortality in the United StatesInternational infant mortality trendsMaternal mortality trendsMaternal morbidityObesity

#Copyright 2016 by Elsevier Inc. All rights reserved.The trends in fertility and birth rates reflect womens need for health care. Review the terminology box 1-6, pg. 8 Low birth weight (LBW) is newborns weighing less than 2500gms or (5lbs, 8oz) are increasing in morbidity and mortality. (twins, multiple births, smoking, are some examples of causes) Non- Hispanic black infants are almost twice as likely as non-Hispanic, white infants to be LBW and to die in the first year of life. Preterm births are those birth before 38 weeks of gestation and 11.5% were born in 2012.Infant mortality in the U.S is an indicator of the adequacy of prenatal care and health of a nation as a whole. Again it is higher in African-Americans than Caucasian and has increased over time.Internationally U.S mortality rate is 6.6/1000 ranked 29th, Canada 5.7/1000 ranking 29th, when compared to other industrialized nations.Maternal mortality trends; estimated 358,000 women died of problem related to pregnancy or childbirth in 2008 this is a decline from 1190 546, 000. In 2010,

Copyright 2016 by Elsevier Inc. All rights reserved.11Regionalization of Perinatal Health Care ServicesAmbulatory careHigh-technology careSocial media and its impactCommunity-based careChildbirth practicesPrenatal care Certified nurse-midwives or physiciansFamily-centered careInvolving consumers and promoting self-management#Copyright 2016 by Elsevier Inc. All rights reserved.A Regionalized system focusing on integrated delivery of graded levels of hospital-based perinatal health care services is effective and results in improved outcomes for mother and their newborns. This system of coordinated care can be extended to preconception and ambulatory prenatal care services. In the ambulatory care providers must distinguish themselves by the level of care they provide. Example Basic care: by obstetricians, family physicians, certified nurse-midwives, provide routine risk-oriented prenatal care, education are examplesSpecialty care provide fetal diagnostic testing and management of obstetric and medical complications.High technology has allowed the care of high risk pregnancies. Maternity care has extended to preconception counseling, more and better scientific techniques to monitor the mother and fetus, more definitive tests for hypoxia and acidosis, and neonatal intensive care units.Social media such as Face book, Twitter and LinkedIn allow nurses with similar interests, share insight about client care, and advocate for clients. However, the pitfall of this technology is for nurses to remember clients privacy and confidentiality can be violated. Nurses can loose their jobs and nursing students can be expelled from their schools.Childbirth practices :Prenatal care will promote better pregnancy outcomes by providing early risk assessment.Certified nurse-midwives or physicians clients have a choice of providers. When women choose midwives, they contribute more in the childbirth decisions, have fewer interventions during labor and less likely to give birth prematurely.More Family-center care- fathers, partners, grandparents, siblings and friends maybe present for labor and birth. Doulas-(trained and experienced female labor attendants) may be present to provide a continuous, one-on-one care to through the laboring process.Involving consumers and promoting self-management: Self management is appealing because of potential to reduce health care costs. Maternity care is especially suited for this because it is primarily health focused, women are usually well when the enter the system and visits to the provider and present the opportunity for health and illness intervention.Copyright 2016 by Elsevier Inc. All rights reserved.12Contemporary Issues and TrendsInternational concernsFemale genital mutilationHuman traffickingWomens healthHeart diseaseViolence

#Copyright 2016 by Elsevier Inc. All rights reserved.#Copyright 2016 by Elsevier Inc. All rights reserved.International concerns are the same basic ones that would make a woman high risk here in the U.S and are listed on page 9. However, female genital mutilations and human trafficking are concerns that nurses in U.S and Canada might also encounter. Nurse have come together and WHO has stated that women all over the world go through these procedure of genital mutilations. The picture below are a group of nurse who climbed the Mt. Kilmanjaro the tallest mountain in Africa to draw attention and raise money to fight against human tracffickng. Womens health- Heart disease remains the leading cause of death of women followed by malignant neoplasm including breast cancer. Violence is a major affecting factor that includes battery, rape or other sexual assaults and attacks with various weapons. Incidence of battering increases during pregnancy.

Copyright 2016 by Elsevier Inc. All rights reserved.13Future of Nursing PracticeTransforming the nursing professionNursing Interventions Classification (NIC)Evidence-based practiceAssociation of Womens Health, Obstetric and Neonatal NursesCochrane Pregnancy & Childbirth DatabaseJoanna Briggs InstituteOutcomes-oriented practiceA global perspective#Copyright 2016 by Elsevier Inc. All rights reserved.A plans have been made to meet the need to assess and transform the nursing process. There are four major messages for nurses , briefly for them practice to fullness of their education and training, 2 to achieve higher education and training, 3, to full partner with physicians and other health care providers in helping to redesigning healthcare and 4, effective workforce planning and policymaking require better data collections. (pg. 10)(IOM)-Institute of MedicineNIC- prepared or developed comprehensive standardized language that describes interventions that are performed by generalist or specialist nurses. For childbearing care- is to assist in the preparations of childbirth before, during and after including breastfeeding assistance, childbirth preparation, circumcision care, electronic fetal monitoring, family planning and kangaroo care.Evidence base-base practice: is providing care based on evidence gained through research and clinical trials is increasingly emphasized. You will see evidence-base practice boxes throughout the texts that provide examples of in perinatal and womens health nursing.The three organizations listed provide data for evidence base practice in different ways. (see p. 10-11).Outcomes-oriented care-measures effectiveness of care against b3enchmarks of standards.Copyright 2016 by Elsevier Inc. All rights reserved.14Standards of Practice and Legal Issues in Provision of CareStandardsANAAWHONNStandards and Guidelines for Professional Nursing Practice in the Care of Women and Newborns (United States)Standards for Professional Perinatal Nursing Practice and Certification in CanadaACNMNANN#Copyright 2016 by Elsevier Inc. All rights reserved.Standards for nursing practice in perinatal and womens health have been described by several organizations, including ANA (American Nurses Association) publishes standards for maternal-child health nursing;AWHONN standards of practice and education for perinatal nurses, (see box 1-8)ACNM-American Certified Nurse Mid-wives- standard of practice for mid-wivesNANN- National Association of Neonatal Nurses,- stands of practice for neonatal nurses. Which I maintain membership because of my neonatal practice.Agencies also have their policies and procedure books for their standards of care.Standard of Care: is that level of practice that a reasonably prudent nurse would provide in the same or similar circumstances. Therefore, for legal negligence, the care given is compared to the standard and if the standard was not met and harm resulted, is determine legal negligence.Legal tip- Standard of Care: Review thisCopyright 2016 by Elsevier Inc. All rights reserved.15Standards of Practice and Legal Issues in Delivery of CareRisk managementSystem of checks and balances to minimizerisk for injurySentinel eventsThe Joint CommissionFailure to rescue: key componentsCareful surveillance and identification of complications Quick action to initiate appropriate interventions and activate a team response

#Copyright 2016 by Elsevier Inc. All rights reserved.Risk management-is an evolving process that identifies risks, establishes preventive practices, develops reporting mechanism and delineates procedures for managing lawsuits.To decrease errors in administration of medication The Joint Commission (TJC) made a list of abbreviations, acronyms, and symbols not to use. In addition each agency must develop its own list. Sentinel events- unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. Sentinel- meaning they signal a need for an immediate investigation and response. (Some examples are maternal death related to the process of birth, see pg. 13.Failure to Rescue- the failure to recognize or act on early signs of distress, was introduced in the 1990s related to adult postsurgical clients. In perinatal this would be placenta abruption, postpartum hemorrhage, uterine rupture, Eclampsia, and amniotic fluid embolism. Fetal complication-include nonreassuring fetal heart rate and pattern, prolapsed umbilical cord, shoulder dystocia, uterine hyperstimulation. Simulation practice can be used to help develop expected roles of team members.Copyright 2016 by Elsevier Inc. All rights reserved.16Standards of Practice and Legal Issues in Delivery of Care (Cont.)Quality and Safety Education for Nurses (QSEN)Teamwork and CommunicationSituation, background, assessment, recommendation (SBAR)Team STEPPSDeveloped by the Department of Defense and the Agency for Healthcare Research and Quality

#Copyright 2016 by Elsevier Inc. All rights reserved.QSEN is an act to provide nurses with the competencies to improve the quality and safety of the systems of health care in which they practice. Box 1-9 are competences for nursing per IOM.SBAR- and Team STEPPS are systems used to help to deliver and provide safe care and communication. Pg. 14 An example of how to deliver SBAR for perinatal client is given in TABLE 1-1, pg. 14.Copyright 2016 by Elsevier Inc. All rights reserved.17Ethical Issues in Perinatal Nursing and Womens Health Care Reproductive technologyAllocation of resourcesOlder-age pregnanciesThird-party payersInduced ovulation and in vitro fertilizationMultifetal pregnancy reductionIntrauterine fetal surgeryTreatment of very low-birth-weight infants#Copyright 2016 by Elsevier Inc. All rights reserved.These are the primary ethical issue in perinatal nursing and women health care. You can review these o pg. 14.Copyright 2016 by Elsevier Inc. All rights reserved.18Research in Perinatal Nursingand Womens Health CareEthical guidelines for nursing researchMust protect rights of human subjectsEnsure that subjects are fully informed and aware of rightsBe sensitive to ethical issues in perinatal researchAnalysis of benefits and risksANA ethical guidelines in conduct, dissemination, and implementation of nursing research#Copyright 2016 by Elsevier Inc. All rights reserved.Research in perinatal nursing has a big ethical component, therefore guidelines for research has been develop. Research provides the science for the maternal and womens health care, but the rights of the clients must be protected.Copyright 2016 by Elsevier Inc. All rights reserved.19Key Points Maternity nursing focuses on women and their infants and families during the childbearing cycle.Womens health nursing focuses on the special physical, psychologic, and social needs of women throughout their life spans.Nurses caring for women can play an active role in shaping health care systems to be responsive to the needs of contemporary women.#Copyright 2016 by Elsevier Inc. All rights reserved.The fours slides provides the summary key points for this chapter.Copyright 2016 by Elsevier Inc. All rights reserved.20Key Points (Cont.)Childbirth practices have changed to become more focused on the family and allow alternatives in care.A variety of factors, including race, age, violence, and human trafficking, affect womens health.Canada ranks twenty-ninth and the United States ranks thirty-first among industrialized nations in infant mortality rates.#Copyright 2016 by Elsevier Inc. All rights reserved.Key Points (Cont.)Evidence-based practice and outcomes orientation are emphasized in current practice.Risk management and learning from sentinel events can improve quality of care.Healthy People 2020 provides an update on goals for maternal and infant health.

#Copyright 2016 by Elsevier Inc. All rights reserved.Key Points (Cont.)Research plays a vital role in establishing a scientific base for the care of women and infants.Ethical concerns have multiplied with the increasing use of technology and scientific advances.

#Copyright 2016 by Elsevier Inc. All rights reserved.The Family in a Cultural ContextChp. 2Cultural factors related to family healthCultureSubcultureAcculturationAssimilationImplications for nursingEthnocentrism#Copyright 2016 by Elsevier Inc. All rights reserved.Cultural knowledge includes beliefs and values about each facet of life and is passed from one generation to the next. Cutural beliefs and traditions relate to food, language, religion, art health and healing practices, kinship relationships, and all other aspects of community, fanily and individual life. Culture has also been shown to have a direct effedt on health behaviors. Values, attitudes and beliefs that are culturally acquired my influence perceptions of illness, as well as health care seeking behavior and response to treatment. Culture shared beliefs and values of a group, pays a powerful role in an individuals behavior, particularly when the individual is sick. When you understand a the clients culture this will provide insight into how a person reacts to illness, pain and invasive medical procedures, as well as patterns of human interaction and expressions of emotion. (Chp. 2 pg. 21) Ethnocentrism- the view that ones own cultures way of doing thing is best. Although the US is diverse, it health practice is base on the dominant culture, primarily Caucasians of European descent. It is important that nurse become culturally competent. You should be familiar with your own beliefs sot that they you have a better understanding of the beliefs of their clients.

24The Family in a Cultural Context (cont.)Childbearing beliefs and practicesCommunication (language, dialects) Use of InterpretersPersonal spaceTime orientationFamily roles

( found on p. 23)#Copyright 2016 by Elsevier Inc. All rights reserved.Nurses care for childbearing families with many different cultures and ethnic groups. (pg. 24) A review from your Health Assessment.25Developing Cultural Competence Key components of cultural competenceRecognizing disparity between ones own culture and that of the clientEducating and promoting healthy behaviors in a cultural contextTaking abstract knowledge about other cultures and applying it in a practical way

#Copyright 2016 by Elsevier Inc. All rights reserved.Pull from Chapter 2 :pg. 27-2826Chapter 5Violence Against WomenMosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.#Copyright 2016 by Elsevier Inc. All rights reserved.Focus on IVP (Intimate Partner Violence) 27Violence Against Women One of every six women worldwide has been a victim of intimate partner violence (IPV)IPV: actual or threatened physical, sexual, or psychologic or emotional abuse by a spouse, ex-spouse, boyfriend, ex-boyfriend, girlfriend, ex-girlfriend, date, or cohabiting partnerOther terms: partner abuse, domestic or family violence#Copyright 2016 by Elsevier Inc. All rights reserved. 28Violence Against Women (cont.)1 in 5 murders in the U.S. are IPV relatedWomen abused during pregnancy have a threefold increase in risk of being murderedIn the U.S., the percentage of women killed by an intimate partner rose from 40% to 45% over a 10-year periodData significantly underestimate prevalence of IPV#Copyright 2016 by Elsevier Inc. All rights reserved.Women Experiencing IPV (cont.)IPV during pregnancyMost women abused before pregnancy will be abused during pregnancy Abuse may happen for first time during pregnancyPeaks during the first trimesterPregnant adolescents are abused at higher rates than are adult womenRisk of fetal injury is high#Copyright 2016 by Elsevier Inc. All rights reserved.Care Management (cont.)Plan of care and interventionsABCDES of caring for abused womenAloneBeliefConfidentialityDocumentationEducationSafety

Pg. 107#Copyright 2016 by Elsevier Inc. All rights reserved.A-Reassure they are not aloneB- Express the belief that violence against the woman is not acceptable in any situationC- The information is not being sharedD- descriptive documentationE- is for Education that violence is likely to recur and escalated. Options, resourcesS- Safety, is most dangerous times for womanPg. 10731QuestionWhen managing health care for pregnant women at a local prenatal clinic, the nurse should recognize that the most significant barrier for access to care is the pregnant womans:AgeMinority statusEducational levelInability to pay#Copyright 2016 by Elsevier Inc. All rights reserved.ANS:DFeedbackA Incorrect: Although adolescent pregnant clients statistically receive less prenatal care, this factor is not the most significant barrier.B Incorrect: Significant disparities in morbidity and mortality rates exist for minority women; however, this is not the most significant barrier to access of care.C Incorrect: Disparities in educational level are associated with morbidity and mortality rates; the educational level is not the most significant barrier to access of care.D Correct: The most significant barrier to health care access is the inability to pay for services. This is compounded by the fact that many physicians refuse to care for women who cannot pay.32Copyright 2016 by Elsevier Inc. All rights reserved.