As National Nutrition Month comes to an end, I am reminded how nutrition isn’t just about cutting calories and eating healthy. There is so much more that we don’t think about on a regular basis, unless it affects the patients in our care or our personal lives.
I regularly visit an adolescent sports medicine facility with one of my children. The clinicians there deal with a variety of conditions and issues, ranging from orthopedic injuries and concussions to eating disorders and, in our case, impaired growth related to caloric expenditure through sport.
Some people may see a kid who is fit and active and think “Wow, he is so lucky!” I see a kid who is competitive to the point that his growth charts have taken some sharp declines during a critical adolescent growth period. While I’m proud of his commitment and determination, I also am concerned for his growth and development.
We are fortunate to have a great resource in our area that has helped us turn things around for my son. He is a swimmer and a runner who trains for hours each day, and to meet his nutritional needs for sport and catch-up growth, he must take in over 5,000 calories each day! Sounds easy, right? Actually, it is a challenge and requires quite a bit of hard work. I ask that you let this post serve as a reminder to be open to the struggles of others; sometimes the problems they face aren’t as simple as you may think.
For some related reading on this topic and more on nutrition, explore Nutrition Today
, a journal with articles written by “leading nutritionists and scientists who endorse scientifically sound food, diet, and nutritional practices,” including the following related to sports nutrition:
NursingCenter is celebrating Certified Nurses Day
, which happens every year on March 19th. Why March 19th? It happens to be the birthday of the pioneer and inspiration behind nurse certification, Margretta "Gretta" Madden Styles, RN, EdD, FAAN.
While we would have been beyond thrilled and honored to interview this innovator in the nursing profession, sadly, Styles passed in 2005 after a long, successful life and career. We thought we would adjust our ‘Nurse on the Move’ blog to feature one of the top ‘Nurses Who Moved’ and truly shaped the profession.
Life and Education
Styles was born in Pennsylvania in 1930. She was married to her husband for 47 years, Reverend Douglas Styles, and the couple had three children.
Styles attended Juanita College and earned undergraduate degrees in biology and chemistry. She went on to Yale University to earn her master’s degree in nursing and then on to the University of Florida, where she earned her doctorate in education.
Nurse educator, author, and innovator
Styles started teaching as an associate professor in 1967 at Duke University and then moved on to become the dean of nursing at various universities, including University of Texas Health Science Center at San Antonio, Wayne State University in Detroit, and the University of California, San Francisco.
Styles campaigned and advocated for stricter certification requirements and credentialing standards for nurses. She wrote at great length on this topic and later helped to create the American Nurses Credentialing Center (ANCC). Her influence on refining the nursing profession in the U.S., extended internationally, and, for a time, Styles also served as president of the Internal Council of Nurses.
While her legacy will always be tied to her role in the creation of the ANCC, her impact on the nursing profession is still widely prevalent. She is often quoted and referenced in medical publications and has had many awards and grants named in her honor. Styles was also inducted into the American Nurses Association hall of fame.
And, of course, the profession will continue to honor Styles’ work and accomplishments on her birthday every March 19th for Certified Nurses Day.
Happy Birthday, Gretta and Happy Certified Nurses Day! Be sure to check our Certified Nurses Day
page on March 19th for lots of great resources and deals to honor this special day.
By Kim Fryling-Resare
Posted: 3/14/2016 8:07:11 AM
| with 1 comments
Last month, new definitions for sepsis and septic shock (Sepsis-3) were released and published in the Journal of the American Medical Association (JAMA). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
is the work of a consensus panel of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. There have been multiple revisions and evolutions to the definitions of sepsis and treatment strategies over the years as we continue to increase our understanding of the complex biology of sepsis and the physiologic effects of sepsis on the body. We are constantly adapting this knowledge to clinical practice. Despite advances in our understanding of sepsis biology, it remains a condition associated with high morbidity and mortality worldwide. Despite constant advances in pharmacologic treatments and organ support devices (i.e. mechanical ventilation, renal replacement therapies, etc.) early identification and treatment of patients with sepsis remains the cornerstone of improving survival. The new definitions simplify the classification of sepsis and provide tools to identify those with suspected infection that are at risk of developing complications of sepsis by utilizing the Sequential (sepsis-related) Organ Failure Assessment (SOFA)
and qSOFA scores.
The new definitions and risk assessment scores take the focus off inflammation and place it on the organ dysfunction related to the dysregulated host response that is sepsis. In fact, Sepsis-3 defines sepsis as “Life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al. 2016).” A lay term definition is also provided in the article describing sepsis as “a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs” (Singer et al. 2016). This provides helpful terminology in speaking with families about the complex and complicated condition.
Why the change?
Prior to the release of Sepsis-3, healthcare providers generally referred to four different levels of sepsis: systemic inflammatory response syndrome (SIRS), sepsis
(SIRS in response to a confirmed infectious process), severe sepsis
(sepsis plus organ dysfunction as evidenced by hypotension or hypoperfusion to one or more organs), and septic shock
(sepsis with persisting arterial hypotension or hypoperfusion despite adequate fluid resuscitation).
Over the years, there has been much controversy over the SIRS criteria, as they are considered to have poor specificity and sensitivity for predicting the development of sepsis. The SIRS criteria – fever, tachycardia, tachypnea, leukopenia/leukocytosis – are present in many conditions, both in chronic medical illness and in acute reactions to infection. A patient with acute bacterial pharyngitis with dehydration from poor intake and tachycardia from dehydration and fever can be treated outpatient and is at very low risk of progressing to septic shock despite meeting SIRS criteria. Furthermore, the “levels” of sepsis infers there is a continuum or spectrum that a patient with sepsis follows in the course of illness and this is not the case.
In a nutshell, the focus of the new definitions as described above is defining sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sequential (sepsis-related) Organ Failure Assessment (SOFA)
is presented as a tool to identify organ dysfunction and the risk of a patient with infection in developing sepsis. SIRS has been eliminated from sepsis vocabulary, as has severe sepsis, which was considered redundant. So now we have:
- Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is measured by changes in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score of two points or more. In a patient with unknown baseline, the beginning score is zero.
- Septic shock: a subset of sepsis with vasopressor requirement to maintain MAP >65 and serum lactate > 2 mmol/L in the absence of hypovolemia (i.e. after a patient has received adequate fluid resuscitation).
The SOFA Score (Vincent et. al 1996) provides clinical measures to identify organ dysfunction; these criteria identify infected patients most likely to develop sepsis. Organ dysfunction is identified as an acute change in SOFA score of greater than or equal to two. These clinical variables include PaO2/FiO2 ratio, platelet count, bilirubin, MAP with and without the presence of vasoactive agents, Glascow Coma Scale, creatinine and urine output.
(Quick SOFA) Criteria is an additional tool highlighted in Sepsis-3. The clinical variables of the qSOFA are:
- Respiratory rate > 22
- Altered mentation (GCS < 15)
- Systolic blood pressure ≤ 100
The presence of any two of these criteria (qSOFA) in a patient with a known infection should prompt further evaluation for organ dysfunction. This tool can be utilized by the bedside nurse.
Nursing implications of Sepsis-3
While these definitions will not change how we treat patients with sepsis or presumed sepsis, they do provide more straightforward terminology, as well as a bedside tool to evaluate a patient with infection, potentially allowing us to both identify at-risk patients sooner and treat earlier. The presence of the qSOFA criteria in a patient with infection should prompt further evaluation of the patient and possible measurement of the more detailed SOFA criteria to evaluate for organ dysfunction. As a nurse, awareness and understanding of the most up-to-date terminology surrounding sepsis improves care of our patients and allows for better communication of patient information to colleagues in a consistent manner. Nurses are in a key position at the bedside to monitor and identify patient in the early stages of clinical decline and have the potential to positively impact patient outcomes by facilitating early interventions and treatment of the septic patient.
With this information, we can improve our communication. In the past, we might have said, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. I just have a feeling this patient is declining; he looks like he might be septic.” Now, with our new definitions, we can say, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. Since admission, he has deteriorated clinically; his qSOFA score is two, he has a respiratory rate of 30 and his systolic blood pressure is 80. When he arrived in the ED, his SOFA score was one due to a creatinine of 1.5. Now his urine output is down to 15 mL/hr, and his MAP is 60. I think we need to order more labs and have someone come re-evaluate the patient for possible transfer to the ICU.” As nurses, we often know when something is changing and our patient’s clinical condition is headed in the wrong direction. Familiarization with these tools provides us with more objective data to present and support our concerns.
It has now been several weeks since the release of Sepsis-3. In reviewing medical commentary, there are varying supports and criticisms of both the new definitions and on the utility of the SOFA and qSOFA scores. True, qSOFA and SOFA are not diagnostic of sepsis or septic shock, the SOFA is a predictor of mortality; but they provide objective data points that can be easily measured in the hospital setting. What remains unchanged is our goal of early identification and early treatment to reduce overall morbidity and mortality related to sepsis. Sepsis is a complex condition; in addition to overt symptomatology, there is complex biochemical, genetic and endogenous factors involved in the pathobiology of sepsis. Some pathways are well understood while others are only on the brink of being understood.
I am personally happy with the new definitions and the simplicity of the diagnostic terms of sepsis vs. septic shock. I am looking forward to the improved dialogue and communication using the SOFA criteria. As with any changes in medicine, there is typically a lag time from publication to implementation. At my hospital, in particular in the ICU, there has certainly been a lot of buzz and support for the new terminology. I would love to hear how other hospitals and facilities have reacted to Sepsis-3!
Megan Doble, MSN, RN, CRNP
Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
Vincent JL, Moreno R, Takala J, et al; Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.
Carolyn Ackerman Ed.D MS RN CHPN, is from Arvada, Colo., and has almost 40 years of experience in home health and hospice. She actually discovered our Nurse On the Move
feature in a recent Home Healthcare Now journal article, Nurse on the Move: Lisa Gorski
, and thought to herself, “Well…why not [me]?”
I had the opportunity to speak to her over the phone to discover why she thought she would make a good candidate, and I am so glad she reached out to us at NursingCenter. Not only is Ackerman a registered nurse, but she is also an assistant professor at Regis University in Denver, and she is very involved in end-of-life interdisciplinary simulation.
Ackerman recently graduated from Creighton University with her Ed.D in interdisciplinary education. She created an end-of-life board game called The Path of Life: The Journey of Living at the End-of-Life © game
, where participants assume the role of the patient as they make decisions related to their terminal disease.
Listen for the whole interview…
For inquiries around Ackerman’s board game and other work, email email@example.com
*Do you know a great candidate to be featured for Nurses On the Move? We want to know about the nurses who are advancing the profession and inspiring others to do the same. Email your submissions to ClinicalEditor@NursingCenter.com
Posted: 3/9/2016 7:51:01 AM
| with 0 comments
By Kim Fryling-Resare
I was going to put together a collection of information and statistics to share about multiple sclerosis, but as I started to write, it became more about what I personally do to raise MS awareness. My hope is that my story will give insight and shed some light onto a patient’s perspective. I feel like understanding is one of the keys to better support and care for patients living with a chronic illness.
March is MS Awareness Month
– a topic near and dear to my heart. I’ve been living with relapse-remitting multiple sclerosis since 2003 and I try to live my life every day as if it is “MS Awareness Day.”
Unfortunately, I’m not a scientist who will discover a cure. I’m not a neurologist or a nurse who will treat patients. And lastly, I’m not fortunate enough to be rolling in money that I could fund clinical trials or research studies. So what can I do to raise awareness about MS?
I can SUPPORT.
Whenever I hear about someone who is newly-diagnosed, or someone who may be struggling with the disease, I’m always ready to hand out my phone number or email address. I know all too well that it can be a continuous struggle, but I want them to know they are not alone. There is hope, and they will get through this battle learning strategies to improve life and ultimately discovering how truly strong they are.
I can stay POSITIVE.
I went through all of the typical emotions after my MS diagnosis, and I had to go through the grieving process and let go of my life, or at least my perceived life, before MS. Now, I’m actually thankful for MS. I have let go of a lot of toxic people and negativity, and I try not to sweat the small stuff. I have chosen to take the path where I value life and take little to nothing for granted.
I can EDUCATE.
I have always been very open about living with multiple sclerosis. I love shocking people with the fact that I have MS. I encourage questions and enjoy sharing my experiences and knowledge. There is a lot of misinformation out there and people tend to have such misconceptions about what MS looks like, and what it means to live with MS. It is such a varying disease that presents so differently and affects people in so many different ways.
I can LIVE fully.
I live the best life that I can with MS, and along the way, I try to educate others on what MS is and what it means to people battling it every day, every month, every year. Raising awareness for MS and living fully is my way of advocating and giving back to the MS community.
I will never give up HOPE.
I have this silly personal belief that if I say something, or believe something long enough, it will manifest and become reality. So…There will be a cure for MS. There will be a cure for MS. There will be a cure for MS…
To continue raising awareness, I’m marking my 13th year living with MS by participating in my first half marathon this summer. 13 years, 13.1 miles! Never give up!
Please use these free resources on NursingCenter to learn more about MS and to help spread awareness by sharing with your colleagues, patients, and the public.
The Journal of Neuroscience Nursing
and the Journal of Infusion Nursing
are both honoring MS Awareness Month by offering subscription discounts in March. Enter promotion code, WFS115GN, and take 40% off the subscription price for either journal.
During these busy days, time management is a challenge for many people. If you have a career where your schedule is frequently changing, the challenge becomes even more pronounced. Maybe you even flip-flop your nights and days sometimes or juggle teaching or taking classes on top of your already busy schedule. The point is, time management skills are essential to keep us rested, healthy, and productive!
Here are some top tips to help you manage your time effectively.
- Write it down. Use a calendar – paper or electronic – to keep track of all your appointments and responsibilities in one place.
- Stay focused. When at work, focus on work. When at home, focus on home.
- Break it down. Divide large tasks into smaller items that are more manageable.
- Declutter. Clear your work area. Whether it’s a desk, medication cart, or bedside table, don’t let excess clutter take your attention away from what you are doing.
- Delegate. Proper delegation and teamwork are time management wins for you and your colleagues.
- Set aside time to answer messages. Answer phone calls, texts, and emails at convenient times, rather than allowing those rings and beeps to distract from your current task.
What other time management tips would you add to this list?
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Posted: 2/29/2016 8:44:39 AM
Lisa Bonsall, MSN, RN, CRNP
| with 2 comments
During the month of February, we celebrate many great traditions – Black History Month, Valentine’s Day, and the birth of our forefathers to name a few. February is also American Heart Month, which was first declared by President Lyndon B. Johnson in 1964.1
Since that time, February has been dedicated to promoting cardiovascular health by many organizations, such as the American Heart Association1
. Heart disease is the leading cause of mortality in both men and women in America.2
It is a disease that can largely be prevented through lifestyle modification1
. Due to advances in medical therapies and better heart disease education, the number of deaths associated with cardiovascular disease has seen a steady decline over the last three decades1
This month brings back many memories for me. My first job out of college in the mid-90’s was in the Intensive Care Unit (ICU) at a large medical center in mid-town Manhattan. This was a unique ICU setting where the staff rotated through the medical, coronary, surgical, and cardiovascular (post-operative) ICUs every few months. It was during these first years that I gained an appreciation for cardiovascular disease and how it could be medically and surgically managed. In the medical ICU and coronary care unit (CCU), I cared for patients who were transferred from the Emergency Room with acute coronary syndrome (ACS) and were awaiting cardiac catheterization for diagnosis and possible angioplasty. The presentation of each patient varied widely. A stable ACS patient with mild symptoms, such as indigestion, could deteriorate rapidly into acute distress and severe chest pain and possibly full code. Stabilizing these patients with aspirin, oxygen supplementation, and sublingual nitroglycerin were critical and electrocardiogram (ECG) monitoring was of the utmost importance. I don’t think any nurse forgets witnessing ST-segment elevation for the first time.
In the surgical and cardiovascular ICU, patients returned from the operating room with a tangle of wires, arterial lines, central lines, pulmonary artery catheters, as well as chest tubes, drains and complex surgical wounds. Monitoring vital signs, titrating IV drips, managing oxygenation and potential bleeding were all part of the post-surgical course. Open-heart surgery patients had to be assessed frequently for elevated jugular venous pressure and pulsus paradoxus (a systemic drop in blood pressure during inspiration3
), both impending signs of cardiac tamponade, an accumulation of fluid in the pericardial space. It didn’t occur too often, but when it did, it resulted in emergency subxiphoid percutaneous drainage – one of the more stressful moments for a new nursing graduate.
After a few years in New York I felt called back to Philadelphia. While attending graduate school, I worked nights in the Cardio-Thoracic Intensive Care Unit (CT-SICU) of a large teaching hospital, caring for patients following open heart surgery. I thought I had seen it all in New York and quickly realized that I had just scratched the surface when it came to caring for cardiac patients. Academic institutions often receive patients with very high acuity due to their ability to offer some of the most advanced treatment options such as intra-aortic balloon pumps (IABP), left ventricular and bi-ventricular assist devices (LVAD and BiVAD), extra-corporeal membrane oxygenation (ECMO), ventilators, and continuous hemofiltration and dialysis. There were moments when I felt more like a mechanic than a nurse working on multiple machines surrounding a fragile life at its center.
Patients typically experience short stays and quick turn-overs in surgical ICUs, however, we had our fair share of patients who spent many weeks and months on our unit. Mr. B.* was one of those patients. Mr. B. was transferred from a local community hospital to our institution with severe heart failure. Mr. B., whose medical therapies had reached a maximum threshold, had been hospitalized multiple times with acute exacerbations of heart failure over the prior year. Each hospitalization worsened requiring increased doses of intravenous (IV) dobutamine and milrinone to improve his heart pumping capacity. Upon arrival Mr. B., who was categorized with Class 4 heart failure (severe), was evaluated by the team for heart transplant. At 64, he was above the upper limit for age exclusion, however he had no signs of lung, liver or kidney disease. He was placed on the transplant list immediately and due to his critical condition the decision was made to place a left ventricular assist device (LVAD) to support his heart. Mr. B.’s post-operative course was riddled with complications. He experienced difficulty weaning from the ventilator and subsequently developed pneumonia. Anticoagulation was carefully titrated to prevent clotting in the LVAD, however this led to bleeding in the gastrointestinal tract. His blood glucose levels rose acutely requiring an IV insulin drip. He battled these challenges and once stabilized, Mr. B. was able to ambulate with his new device and begin rehabilitation in preparation for his transplant. He was extremely positive, cracking jokes with the nurses and always smiling. I could tell he was truly grateful for each day he was alive. Today, LVAD patients may be discharged home and are able to live comfortably with the device, some as a bridge to transplant and some as destination therapy if transplant is not an option. Mr. B. was with us for several weeks due to his complications, but was eventually discharged home.
One cold November morning, Mr. B. and his family were notified that there was a donor heart available and that he was a match. He was admitted back to our unit that afternoon and later that evening he received the gift of a new heart and a second chance at life. The surgery went extremely well. Mr. B. spent four days of recovery in the CT-SICU where we monitored him closely for rejection. He was then transferred to the general surgical ward for cardiac rehabilitation and was discharged from the hospital on post-op day 15.
The most gratifying part of being an ICU nurse is seeing your patients recover. Mr. B. returned often to say hello and thank you, which always warmed our hearts. He is one of many cardiac patients I will never forget. While Mr. B.’s story ends well, many more patients with cardiac disease are not as lucky. We as healthcare providers should continue to emphasize the importance of heart health education and lifestyle modification to prevent the progression of cardiac disease. Happy American Heart Month to all!
*Note: Any identifying characteristics are coincidental.
Myrna B. Schnur, RN, MSN
Center for Disease Control and Prevention (2016) Heart Disease Facts. Retrieved from http://www.cdc.gov/heartdisease/facts.htm
It can get complicated to juggle our personal and professional lives. This infographic will help you take a closer look at what you need to do to keep yourself healthy – physically, mentally, and emotionally.
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The secret to getting ahead is getting started ~ Mark Twain
As nurses, there are many different roads we take on our journey to where we are now professionally. We all have different starting points and are currently at different places on this professional road. Similarly, there is immense variation in how we set and achieve our goals. There are volumes of literature on goal setting and achievement and the methods are not a one-size-fits-all formula. The key to successful goal management is figuring out what works for you, being honest with yourself about what your current and future goals are and coming up with a plan to achieve what you set out to do. Personality, life circumstances, and family-work balance all play roles in how we set and achieve goals, as well as our motivation to accomplish them.
Personally, I began my professional career in medical research with a degree in the sciences. I quickly determined that I wanted to interact with patients rather than study them from inside a room (my project involved taking measurements on carotid arteries [recorded loops on VHS] – in a dark room – as part of a cardiovascular research project). When I came to this realization, I organized my first five-year plan with a goal of becoming a nurse. I applied to and was accepted to a nursing program. I went on to receive my BSN and subsequently my MSN, which I completed in 2001 with the help of a National Health Service Corp Scholarship. I began working at a Federally Qualified Healthcare Center as a Family Nurse Practitioner. and after fulfilling my commitment to the scholarship, I was able to do a loan repayment program at the same health center. Within five years, I had all of my undergraduate and nursing loans payed off. Using the five-year framework allows for short and long-term goal setting with some flexibility factored in for the unexpected. While I personally work better with this flexibility, others may find more success with a stricter plan; this is where we need to be honest with ourselves and come up with a method that works best.
Fast forward eight years. Following a job transition, I was offered a position working in an ICU as a nurse practitioner. Although this was not in my original plans, and well out of my comfort zone, the opportunity was one that I could not pass up and presented an exciting new challenge. Around this same time, the Consensus model for APRN regulation: Licensure, accreditation, certification, and education
(APRN Consensus Work Group, 2008) was released. This landmark publication for NP practice essentially recommended that NPs practice in the discipline/setting for which they were educated and certified. Although this seems straight forward, NP history is one whose roots began in primary care with evolution to the acute care setting. Educational programs for acute care NPs were introduced later in the historical timeline, and the fact is that there are many primary care NPs practicing in hospitals. So now, with no plans to leave the ICU, my current five-year plan includes completion of a post-master’s program to become certified as an adult-gerontological acute care nurse practitioner. This was an adjustment I needed to make, but it is a great opportunity to improve my skills and my job performance.
I mentioned the flexibility to my plans earlier. There was an approximately five-year period in my life (i.e. when my children were infants) when I struggled to keep up with my plan, or rather, I had no plan! Memories of these years include crunching to find online CME and overnight expressing my license applications and sometimes struggles to just get through the day. For me, despite being a competent nurse at work, I found it overwhelming trying to figure out parenting and how to be a working mom. The learning curve of parenting and navigating the work-life balance was steep. Eventually, I was able to get back on track. Moving forward, I have reset my five-year plan once again (it’s a moving target). I hope to complete the acute care NP program in December 2016 then take and pass (fingers crossed) the exam in the spring of 2017. After that, I may try to teach, or possibly consider a DNP or PhD program.
I have not done extensive research from an academic or literature perspective on goal setting, but I do know that there are many successful methods for those that have difficulty with a flexible plan or prefer a more established format. For myself, it has been immensely helpful to take time, every so often, to reflect on where I am and where I would like to be. NursingCenter’s blog post, My Nursing Care Plan for 2016
, provides an excellent resource for some of our requirements to keep up our professional obligations. Because in addition to our professional goal, there are tasks that we need to complete to stay current and licensed.
How do you like to set and achieve your goals? Has anyone found a more standard goal setting process that works for you? Please share your experiences with us!
Megan Doble, MSN, RN, CRNP
Lifelong learning is essential for your professional development and to ensure evidence-based patient care and improve outcomes. Use this infographic to help you stay on track and meet your goals!
Use My Nursing Care Plan for 2016
for a full look at assessing, planning, and implementing your goals for the year ahead!
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