Radiation Therapy Types

Types of Radiation Therapy

• Radiation therapy kills cancer cells, shrinks tumors, decreases pain, and relieves obstruction using high-energy radiation
• External beam therapy applies radiation from a source close to the body's surface
• Internal radiation therapy uses radioisotopes placed directly into the tumor (brachytherapy) or the systemic circulation

Eternal Radiation Therapy

• External radiation delivers radiation from a source at a distance based on tumor depth
• Higher energy beams penetrate deeper
• Gamma ray machines include linear accelerators, cobalt, betatrons, or radioisotope-containing machines
• Kilovoltage treats superficial skin and breast lesions
• Neutron beams treat salivary gland tumors and sarcomas
• Therapists monitor clients via closed-circuit television and intercom without remaining in the room during treatment
• Treatment occurs for 15-30 minutes daily, 5 days per week, over 2-7 weeks in an area marked by a radiation oncologist with semi-permanent ink

Internal Radiation Therapy

• Internal radiation places radioactive isotopes into the tumor (brachytherapy) or systemic circulation
• Temporary internal radiation involves high-dose radiation for brief periods
• Permanent internal radiation involves low-dose radiation for extended periods
• Needles, seeds, heads, or catheters can implant internal radiation into body cavities (vagina, abdomen, pleura) or interstitial compartments (breast)

Types of Internal Radiation

• Sealed sources enclose radioactive material within a container
• Unsealed sources administer radioactive material systemically, such as iodine-131 for thyroid carcinomas, either by injection or orally
• Intraluminal brachytherapy delivers radioisotopes via catheters into organ lumens to treat tumor beds, such as obstructive lesions in the bronchus, esophagus, or bile ducts
• Intracavitary radioisotopes commonly treat gynecological cancers
• Radioisotopes are inserted into positioned applicators verified by x-rays, remain for a prescribed period, and then are removed/left in place
• Movement is limited using bed rest and log rolling to prevent device displacement
• Interstitial implants use temporarily or permanently positioned seeds, needles, or wires in the prostate, pancreas, and breast
• Partial breast radiation uses mammosite devices and inflatable balloons with seeds inserted, for 5 days
• Systemic brachytherapy involves the administration of radioactive isotopes through IV or oral routes using iodine-131 for thyroid cancer and phosphorous 32 for ovarian cancer
• Radioimmunotherapy uses a radionuclide in NHL attached to a monoclonal antibody

Side Effects of Radiation Therapy

• Acute side effects include nausea, vomiting, skin desquamation, and dermatitis
• Late side effects include fibrosis, alopecia, lymphadenoma, pneumonitis, secondary cancers, cardiac problems, intimal thickening of arteries and arterioles, capillary and venule dilation, reduced capillary vascular beds, ischemia, and fibrosis
• Side effects also classify based on the organ system

Management of Radiation Therapy Side Effects

• Symptom and system-wise treatments address side effects
• Diarrhea is manageable with IV fluids and mineral/nutrient supplementation
• Fibrosis and dilation of veins and arteries are manageable by increasing physical activity
• Optimal activity level and physician-prescribed exercise programs are considered as patient safety, and prognosis levels are considered
• Physical and occupational therapy is considered
• Sleep restriction involves limiting naps and rest times to prevent extremities swelling due to blood pooling
• Sleep hygiene and consistent bedtimes should be maintained
• Psychosocial interventions, stress management, and relaxation techniques can reduce psychological distress
• Support groups can help patients divert their minds and relieve consecutive distress periods

Adverse Effects to Cancers

• Depression is associated with breast, lung, pancreatic, oropharyngeal, and brain cancers; risk factors include a personal or family history of treated depression
• Exercise, sleep hygiene, stress reduction, cognitive and relaxation therapies are the treatments
• Fatigue is associated with brain, head and neck, breast, lung, pelvic, and lymphatic system cancers; risk factors include low Karnofsky performance score, active cancer, and being female; exercise, sleep hygiene, stress reduction, cognitive and relaxation therapies are the treatments
• Dermatitis is associated with head and neck, breast, prostate, and perineal cancers; risk factors include obesity, concurrent chemotherapy, and high body mass index: topical steroids routine skin care with mild, unscented soap is the treatment
• Radiation recall is associated with chemotherapy agents such as doxorubicin, fluorouracil, hydroxyurea, methotrexate, and paclitaxel, treatments are the same as for dermatitis
• Younger age, longer follow-up, and increased radiation dose are risk factors for cardiovascular disease associated with Hodgkin lymphoma, breast, and lung cancers; the treatment are that of that of awareness, although no definitive guidelines for cardiovascular screening
• Pneumonitis is associated with breast, lung, and mediastinal cancers; risk factors include elevated concentrations of radiation dose, and volume of lung irradiated, concurrent chemotherapy comorbid lung disease, poor baseline pulmonary function test, and low Karnofsky
• Steroids pentoxifylline is the treatment of pneumonidis
• Concurrent chemotherapy is a risk factor for head and neck cancers associated with xerostomia, treatment consists of saliva stimulants and substitutes; pilocarpine amifostine for prevention and treatment
• Increased radiation dose, concurrent chemotherapy is associated with head and neck, as well as thoracic cancers causing mucositis and esophagitis; treatments include viscous lidocaine, proton pump inhibitors, promotility agents, bland diets, and avoidance of alcohol, coffee, and acidic foods
• Abdominal and pelvic cancers can cause enteritis diarrhea and increase radiation levels, hypertension, diabetes mellitus, as well as prior abdominal surgery, and prior pelvic inflammatory treatments include is low-residue diet, stool softeners, loperamide, and small amounts of dairy products
• Anal, rectal, cervical, uterine, prostate, bladder, and testicular cancers can cause Proctitis which is increased levels concurrent chemotherapy, inflammatory bowel, and disease treatments that include sulfasalazine by mouth, sucralfate enema for chronic proctitis, and hyperbaric oxygen
• Upper abdominal, craniospinal, and pelvic cancers can lead to emesis, due to prior chemotherapy, fields above 400cm radiation to the upper abdomen, and total body irradiation treatments include receptor antagonists-hydroxytryptmine and steroids, as well as dopamine antagonists, and acupressure
• Prostate, colorectal, bladder, and pelvic cancers can lead to cystitis which is concurrent chemotherapy and a treatment that consists of, intravenous hydration, uroprotective agents, hyperbaric oxygen for hemorrhage, and symptomatic care for chronic cystitis
• Prostate, colorectal cancers cause erectile dysfunction which is pretreatment erectile dysfunction and concurrent androgen ablation therapy, brachytherapy treated with phosphodiesterase type 5 inhibitors, counseling and therapy
• Cervical, endometrial, and vaginal cancers cause vaginal dryness and stenosis which is age older than 50 years increases risk of stenosis which is treated with lubrication, a vaginal dilation, and counseling therapy
• Cervical, pelvic, and testicular cancers cause infertility and teratogenicity, which is treated with egg and sperm preservation or ovarian transposition and can be made worse if their, age is older than 40 years with a greater dose to ovaries

Benign and Malignant Tumors

• Benign tumors are abnormal cell lumps or growths of normal cells; tumors are cancerous (malignant) if composed of abnormal cells with uncontrolled growth
• Benign tumors do not invade nearby tissues or metastasize and are less worrisome, examples include fibroids in the uterus and lipoma
• Malignant tumours are made of cells that can invade nearby tissues and migrate into the bloodstream or lymph nodes to spread elsewhere in the body (metastasis)

Benign Tumor Characteristics

• Cells tend not to spread
• Grow slowly
• Do not spread to nearby tissue
• Do not metastasize
• Tend to have clear boundaries
• Normal cell appearance under a microscope
• Do not secrete hormones or other substances

Malignant Tumor Characteristics

• Can spread
• Usually grow fairly rapidly
• Often invade basal membrane that surrounds nearly healthy tissue
• Can spread via bloodstream or by sending "fingers" into tissue
• May recur after removal, sometimes in other the original site
• Cells have abnormal chromosomes characterized by large, dark nuclei along with an abnormal shape
• Can secrete substances that cause fatigue and weight loss (paraneoplastic syndrome)
• May require aggressive treatment

Cancer Warning

• Change in bowel or bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening or lump
• Indigestion or difficulty in swallowing
• Obvious change in wart or mole
• Nagging cough or hoarseness

Tumor, Node, Metastasis (TNM) staging system

• The TNM system is the most widely used cancer staging system
• "T" refers to the size and extent of the main (" primary ") tumor
• "N" refers to the number of nearby lymph nodes that have cancer
• "M" refers to whether the cancer has metastasized

TNM Meaning

• Tx: Tumor cannot be evaluated due to lack of information
• T0: No evidence of a primary tumor
• T1*: Tumor was not detected during a digital rectal exam and cannot be seen on imaging studies
• T2: Tumor can be detected during a dre but is present in the prostate only
• T2a: Tumor is in half or less than one side of the prostate
• T2b: Tumor is in more than half of one prostate lobe, but has not yet invaded the other lobe
• T2c: Tumor is in both prostate lobes
• T3: Tumor extends outside of the prostate
• T3a: Tumor extends outside the prostate on one or both sides
• T3b: Tumor has spread to the seminal vesicles
• T4: Tumor has spread to tissues near the prostate other than the seminal vesicles, such as the bladder or wall of the pelvis
• Nx: Nearby lymph nodes are not evaluated
• N0: No cancer cells are found in nearby lymph nodes
• N1: Cancer cells are found in nearby lymph nodes
• M0: Cancer has not spread beyond the prostate
• M1: Cancer has spread beyond the prostate
• M1a: Cancer has spread to distant lymph nodes
• M1b: Cancer has spread to bone
• M1c: Cancer has spread to another organ or site, with or without bone disease

Cancer Stages

• Stage 0: Abnormal cells are present but have not spread; also called carcinoma in situ (CIS)
• Stages I, II, and III: Cancer is present; the higher the stage number, the larger the cancer tumor and the greater the spread to nearby tissues
• Stage IV: The cancer has spread to distant parts of the body
• In situ Abnormal cells are present but have not spread
• Localized Cancer is limited to the place where it started, with no sign that it has spread
• Regional Cancer has spread to nearby lymph nodes, tissues, or organs
• Distant Cancer has spread to distant parts of the body
• Unknown there is not enough information to figure out the stage

Chemotherapeutic Agents

• Chemotherapy stops cancer cell growth by killing the cells or stopping their division and cell-cycle is non-specific.
• Chemotherapy administration done orally, by injection, infusion, or topically, depending on the cancer type and stage

Types of Chemotherapy

• Alkylating agents are more effective while the cell is resting
• Mustard gas derivatives include Mechlorethamine, Cyclophosphamide, Chlorambucil, Melphalan, and Ifosfamide
• Ethylenimines include: Thiotepa and Hexamethylmelamine
• Alkylsulfonates: Busulfan
• Hydrazines and Triazines: Altretamine, Procarbazine, Dacarbazine and Temozolomide
• Nitrosureas: Carmustine, Lomustine and Streptozocin act by crossing the brain barrier to treat brain tumors
• Metal salts: Carboplatin, Cisplatin, and Oxaliplatin

Plant Alkaloids

• Plant alkaloids are derived from certain types of plants
• The vinca alkaloids are made from periwinkle plant (catharanthus rosea)
• The taxanes are made from the bark of the Pacific Yew tree (taxus)
• The vinca alkaloids and taxanes are also known as antimicrotubule agents
• The podophyllotoxins are derived from the May apple plant and the Camptothecan analogs are derived from the Asian "Happy Tree" (Camptotheca acuminate)
• Podophyllotoxins and the Camptothecan analogs are also known as topoisomerase inhibitors, and this the type of cell-cycle specific
• Vinca alkaloids: Vincristine, Vinblastine and Vinorelbine
• Taxanes: Paclitaxel and Docetaxel
• Podophyllotoxins: Etoposide and Tenisopide
• Camptothecan analogs: Irinotecan and Topotecan

Antitumor Antibiotics

• Antitumor antibiotics are chemo treatments made from natural products produced by species of the soil fungus Streptomyces, which is cell-cycle specific
• Anthracyclines: Doxorubicin, Daunorubicin, Epirubicin, Mitoxantrone, and Idarubicin
• Chromomycins: Dactinomycin and Plicamycin
• Miscellaneous: Mitomycin and Bleomycin

Antimetabolites

• Antimetabolites are very similar to normal substances within the cell, when cells incorporate the substance in their metabolism, they are unable to divide, and this is classified as cell-cycle specific
• Folic acid antagonist: Methotrexate
• Pyrimidine antagonist 5-Fluorouracil, Floxuridine, Cytarabine, Capecitabine, and Gemcitabine
• Purine antagonist 6-Mercaptopurine and 6-Thioguanine
• Adenosine deaminase inhibitor: Cladribine, Fludarabine, Nelarabine and Pentostatin

Topoisomerase Inhibitors

• Topoisomerase inhibitors interfere with topoisomerase enzymes to control DNA structure during replication
• Topoisomerase I inhibitors: Ironotecan, topotecan
• Topoisomerase II inhibitors Amsacrine, etoposide, etoposide phosphate, teniposide
• Miscellaneous Antineoplastics : are unique drug types
• Ribonucleotide reductase inhibitor: Hydroxyurea
• Adrenocortical steroid inhibitor: Mitotane
• Enzymes: Asparaginase and Pegaspargase
• Antimicrotubule agent: Estramustine
• Retinoids Bexarotene, Isotretinoin, Tretinoin (ATRA)

Nurses' role in administering Chemotherapy

• It is the nurse's responsibility to ensure the family, carers, or others are adequately informed about the treatment and administration process
• Family education and information should be based on the patient's reading level, literacy and level of understanding of information provided
• Patient education and consent processes must be completed and documented according to local institute requirements

Nurse must ensure

• The planned treatment is verified and understood by the patient
• All therapy medications are stored appropriately before administering
• Verify the medication order (including with chemo) according to the protocol, check the treatment plan, patient laboratory etc
• The therapy administered with the treatments and in a safe and timely manner
• Any short term/or long term side effects are appropriately managed
• All professional legal responsibility is met with respect to administration to medication

Pre-chemo Administration Assessment

• Medical history, medications used in the past for cancer treatment history, and any other ailments
• Obtain signed consent form for patients and check for allergies
• Perform an original medication order for treatment, with parameters (height, weight, BSA, age) in correct data and all laboratory tests

Therapy Product Check

• Ensure nursing staffs are familiar with the therapy and its related adverse side effects expected to occur.
• Ensure policies, procedures and equipment required for the safe administration and handling of cytotoxic chemotherapy is available

Complete Assessments

• Completion of therapy
• Addressing the questions regarding compliance, as well as addressing psychosocial concerts and side effects
• All of these side effects must be identified with the nurse pharmacist prior to administering the medication and must be documented

Preparing administration of chemo

• Obtain all cancer therapy related medication to be administered, this includes pre-existing conditions that they will need
• Have in your position during, administration PPE, infusmion pump. And any other related equipment

Pre & Post administering Chemo

• Administration of pre-medications allowing certain time frame, before chemo-administering process
• Make sure the antiemetic is taking 30 min and follows right adminitstration protocol
• Pre-medications shouldn't be taken too early(60 min)
• Dexa-metha-zone may be self administered

Administering Route Checks

• Preparations that may be visual sign of any parental, and must seek advice for providing pharmacist
• CVAD (Central Venous access devise) for infusions of medications
• Chemo and targeted therapy should be administered, during operational hour to get maximum outcome with patient
• Intravenous lines, in accordance to local standards
• Staff member should be fully knowledge with extravasation which includes risk of hypersensitivity and also able to follow local protocol

Administration Information

• Programming the infusion pump, should be followed by two competent licensed nurse
• Correct rate, according to time span required depending on smart pump of your choice
• After it is set, with new rate being monitored, should do continuous Clinical Hand over
• After, give a full volume of complete Fluid, to ensure it properly clears

IM & SubQ Route checks

• If needed checks and cautions must applied if you use intramuscular and subcutaneous routes
• Intra-muscular, injected deep
• Subq =admin through epidural and dermis layers and all sides are also to be rotated

Interthecal Routes and Information

• Same IV Route applies
• Ensure staff, knows about checking the specific catheter, so they understand the catastrophic outcomes
• Have a register of all the competent staff, so they can use specific type of therapy. With cancer.
• Having two staffs so “time out” doesn’t cause unnecessary interruption

Oral Routes

• Need the same checks as if you are about to inject
• It carry the same high risk
• Pt need to swallow, but have nothing that put pt in danger

Post Treatment Actions

• Nursing staffs must ensure that all medication administration occur according to, treatment plan (Mesna, folinic acid), all with fluid requirements
• Check protocols depending on pt state

Further Actions By RN Post treatment Process

• After, RN must handle the waste. According to what is going on and which route you use. How much dose and what is life, follow for 7 days
• Prior to discharge check for, what the side effects, any precautions, info what to do
• Ensure arrangements are made, for test to treat certain Dx, with appoitment with doctor

RN must supply and manage

• Make sure you and the pharmacist are, in conjunction. That you both are in supply that is readily available, anti-diarrheal etc.
• Also make sure this information is provided by pharmacists
• There also must be documentation when doing all this stuff

Breast Cancer Risk Factors

• Physical inactivity is increased; the American Cancer Society should engage for 45 min for every day
• Alcohol consumptions can elevate liver function limiting blood test for hormone level
• Smoking can also play a role in B cancer
• Exposures in estrogen also influence this from, hormone replacement therapy, taking estrogen for 10+ hrs or weighing to much or regularly drinking

Prevention

• Recent oral contraceptive influence on Women
• Stress and anxiety also can have major influences

Breast Cancer Diagnostic Measures

• Core needle biopsy to analyze if cell are cancerous, with fluid or some type of mass is removed
• Biopsy samples are sent to look for cells or types of cells, to determine their aggressiveness, or what hormones their receptors have
• MRI uses waves with radio to capture images rather than a scope; patient will be injected with a dye to read the images

Breast Cancer: Rehab Considerations

• Rehabitation is important to those how had chemo radiation or surgery, after or before
• Time to rest, immediately post time of surgery
• Expect to have limited arm, movements especially with lymph node surgeries occur, for the 1st week
• Heal the blood and lymphatic the blood with the help of drains on the site
• Arms should be kept around 90 degrees side of the recovery pt. With no heavy lifting

Therapy & Exercise to manage pain

• When doctor approves can start the shoulder roll type workout, with the deep breathing
• Sleeping will be painful must sleep on wedges with pt
• Those with exercises for 3-5 hours a day greatly improve over the 40 percent and less active
• Treadmill slowly provided significant benefit

Therapy Appointments Consist of

• Examining your surgical site, assess of swelling or pain, checks for current mobility as we as arm shoulder
• The phys therapist will design some workout , or at their facility. Remember stay in range, do not stress yourself , follow them and do not breakdown"
• To perform exercises properly:
  • Aerobic- 150 week with week with moderate intensity
• Resistance to activate muscles in 2 days a week
• Flex- stretching major groups on tendon

Colon Cancer

• In regards to risk lifestyle factors, influence to get the worst
• Those you weigh heavy is also a negative catalyst to get the Dx
• For Physical inactivity, if you do not perform the best you can get it
• Types of meat that are high to make it risker or cooked at extreme heat also have high chances
• Smoking also has links of lung cancer;
• Heavy alcohol will increase your chances.
• Being of older age is also factor, but most of these things is usually the catalyst
• A personal HX of adenomacous colon Ppolyds with dysplegia
• Having a genetic syndrome from fam member or being a syndrome in itself
• High risk, would mean that you will have increased change so will need to have early Dx, from doctors

Managing Dx, for Colon Cancer

• Colonoscopy is when sedation is used and the entire colon, is scoped to look for a tumor
• Biopsy in microscopic for an exam to look for small tissue on the tumor
• Molecular testing from genes testing and protein

Blood tests will monitor the patient

• CT is x ray that scans and uses angles to measure the body
• MRI uses not X rays with big magnets for the body
• X-rays is the cheapest version
• PET is combined X rays and body CT

Patient Plan

• Protect The Stoma; the skin need to look around, so it cannot get tender or sore
• Using A Sizeable Pouch; to avoid large amounts of the stool
• Must change the Pounching System Regularly; for less skin imitation, do not itch and burn it
• Carefully Pull System; be careful not too pull to damage the membrane, dry the colon
• Take Caution & Observe for Allergies; allergies, or problems for week month years, as well check stoma nurse
• Colon is need so for descenting signoid irrigation
• Irrigation better Meal or after hot or warm drink the clamp to irrigate with the supplies, and the tubing,1000 cc, Then set water
• Make patient to sit in the bowl or straight
• Wet any cones, while in the stoma
• Remove Bubbles From tubbing, small amout
• Then pull down the stoma to see where it meets the skin
• Try too put it, until a release the content

Colon Content

• Should always hold the tip as needed, the amount of water depend on pt
• Shouldn’t Crap and Nausea; but if so water is going to soon, you are over and above, pt
• Check Seal of the Water or pouch after irrigation or seal
• Patient will make changes to make bag work better; that means for tissue issue paper to clean the system
• Empty the pouch is always best

Colon Health Checks

• Sit as far back it can
• With a small strip of paper
• Clean out anything after all that make it like a roll
• What it looks like?
• Most has what it is and best is to change it depending on how long is last
• Factors how this seal system is at, Skin has problems with scars, climate, body in or out, and nature
• Be mindful
• Don’t make it to warm, don’t wear the system pouch for days

Colon Irraritions

• May Cause, order always check first or contact the nurse

If there is a Diarrhea

• Must keep it clean but right
• The colon is a warning that needs to be right for the body, usually meaning frequent loose of water
• Electrolyte imbalance; is the risk
• Must be careful with nutrition, and hydration
• Check is has symptoms such as drowsiness with some more sodium loss, call right away if emergency

Other Issues

• The phantom rectum is very similar to the removal limb
• Short bowel if is the large removal, then make sure you give enough in the diet

In case of CRAMPS & OTHER SYMPTOMS Educated

• Seek immediate help
• Crams are lasting more. Than 2 our 3 hours
• With Continuous Nausa
• No output for 4-6 hours
• Severe watery , but is only doing so after 5-6 hours
• Bad orders more than 1 week (is in sign for infection")
• Cut’s in the Stoma
• Always remember Injury in stoma and any Irratation

List of the bleeding from the stoma:

• Must watch Stoma, note anything in pouch (remember to use beets)
• Always watch for bleeding

Discuss the post operative nursing management of Mr. Suresh

The post operative nursing diagnosis would be Acute Pain

• May be related to
  • Disruption of skin, tissue, and muscle integrity; musculoskeletal/bone trauma
  • Presence of tubes and drains

Possibly evidenced by

- Reports of pain 
- Alteration in muscle tone; facial mask of pain
- Distraction/guarding/protective behaviors
- Self-focusing; narrowed focus
- Autonomic responses

Objective;

- Report pain relieved/controlled.
- Appear relaxed, able to rest/sleep and participate in activities appropriately.

Nursing Implementations and Rationale

• Evaluate pain regularly (every 2 hrs noting characteristics, location, and intensity (0-10 scale). Emphasize patient's responsibility for reporting pain/ relief of pain completely. Is is to provides info about need or the best way to resolve
• Note: Headache needs more attention, fluid increase and should notify the anesthesiologist

Other Implementations

• Assess vital, sign with pt denied, can cause discomfort
• Check, catheter (with blood or air fluid)
• Reposition in Sims-Fowler"s and reduce the belly
• Provide extra back or heat
• Encourage for relaxation, with music as needed
• Administer with Medication:

Nursing Management Continued

• Analgesics IV, depends on side and effect
• Patient controlled PCA monitoring with help
• As local anesthetics to reduce damage
• Nasids; helpful to help reduce

Other Impairment

• There can be many different type of clear if airway, may affect in some way because of
  • Copious -energy -artificial air way
• Thinks secretions

Implementation of Airway

• Changes the BP, HeatRate, temperature
• Assess respiratory, rate and quality
• Auscultate lungs, check reduced lungs that the patient may has
• Assist the strength of coughing- is patient ok

If the Patient

• Aspiration so the nurse to station
• With easy help and the right care-give the info
• Easy will client will be with and the new will lead easy
• The body is ready or not will cause some type of communication pattern
• Frustration and the objective

Implementation of Communication

• Communication
• Assess or what other method help if it is not working what method will
• Provide for it as a client to take care all situation

Objective

• Is there anything that he/she will express to help him her, out. Or can him or those skill out for life?
• Know about what help; does need to know what has going on
• Assess what you or can help him/her know
• Explain how does the situation about what about that you take that step

Home support from Care

• Support the site while have good care
• Home is the must care must will tell the person of their situation etc
• Always have help always do everything step by step

If there is infection what to be aware of

• Increased
• Such all of where is
• The surgical

Goal

• How is white flood flow, etc..

Care plan with Imparied

• Is the best way have more attention, all will need help you, or get the right point on where the person feels, what there and why they are needed
• Note you need to also be with then before. You get someone need that level what is that it has to do with
• So how you make will what get what that can the you
• Also is going is that what can those need in the life