Surgeon General, RN

Sylvia_Trent-Adams_Official_Portrait.jpgIt is an exciting time for nursing! On Friday, April 21, 2017, Rear Adm. Sylvia Trent-Adams, became one of the first nurses to serve as Surgeon General of the United States.

Trent-Adams was a nurse officer in the Army and also served as a cancer research nurse at the University of Maryland. In 1992, she joined the Commissioned Corps of the Public Health Service and was the deputy associate administrator for the HIV/AIDS bureau of the Health Resources and Services Administration. In November of 2013, Trent-Adams joined the office of the Surgeon General as   the 10th chief nurse officer of the U.S. Public Health Service (USPHS).

I look forward to seeing Trent-Adams’ impact on public health. Based on what I’m learning from her biography and her quotes in the articles below, I believe her nursing background will positively influence her decisions and actions.

In a 2014 Profile in American Journal of Nursing, Trent-Adams is quoted as stating:

“Nurses bring common sense to solving problems, which has not been recognized enough,” she said. “Nurses spend more time with the patient than any other health care provider.”
 
In 2015, American Journal of Nursing profiled Monrovia Medical Unit (MMU) Team 1, a group who spent 60 days in Liberia operating a 25-bed Ebola unit outside the capital city, with the specific intention to treat health care workers.

Rear Admiral Sylvia Trent-Adams, chief nurse officer of the USPHS, went to Monrovia with the team as commanding officer of the Commissioned Corps Ebola Response. She said the team "did an outstanding job." They provided "high quality care and treatment services, which were often described by our international partners as the best available care in the country," she said. "Each day we strive to 'protect, promote, and advance the health and safety of our nation,' and this mission was no different."
 
I am proud to see a nurse assume this leadership position. It is an exciting time for nursing, indeed!
   
 
Posted: 4/25/2017 3:30:24 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Leadership


Transplant Nurses Day


transplant-nurses-day-logo.jpgApril 19th is Transplant Nurses Day, hosted by the International Transplant Nurses Society (ITNS). Beginning in 2006, this recognition day raises awareness “of the unique contributions transplant nurses make in the lives of the people with whom they work, especially their patients,” and takes place on the third Wednesday in April.

According to the U.S. Department of Health & Human Services, there are over 119,000 people in the U.S., currently on the national transplant waiting list, and there were “30,970 transplants performed in 2015 – the first year [to exceed] more than 30,000 transplants.” Each day, around “80 people receive organ transplants,” and the Organ Procurement and Transplantation Network reports there were 5,367 transplants performed between January and February 2017.

Transplant nurses and transplant nurse coordinators are a vital part of the organ donation and transplantation process. Transplant nurse coordinators work with patients throughout the process, from evaluation for transplant and getting listed to post-transplant care. Transplant nurses prepare living donors and inform them of any risks involved in donating. They also care for patients who receive essential organs from living donors, assist the medical team during surgery, manage patients during post-operative care, and monitor for organ rejection.
 
Without transplant nurses, transplant centers and programs could not function. In celebration, here are some resources related to transplant nursing:
 
•    Organ Donation Collection – worth 7 contact hours!  CE-badge.pngCore Curriculum for Transplant Nurses
•     Primary Care Management of the Liver Transplant Patient CE-badge.png
•    Issues in Organ Procurement, Allocation, and Transplantation CE-badge.png 
•    Core Curriculum for Transplant Nurses
•    Immunosuppression in Solid-Organ Transplantation: Essentials and Practical Tips
•    A Review of Organ Transplantation: Heart, Lung, Kidney, Liver, and Simultaneous Liver-Kidney





Thank you, transplant nurses, for all that you do! 


 
Posted: 4/19/2017 1:05:16 PM by Cara Deming | with 0 comments

Categories: Clinical topics


Nurses – Get on board!

I must admit, when discussions about nurses on boards transpired here in our office, I wasn’t exactly sure what that meant. Nurses provide patient care – it’s what we study, it’s the work we do, and for many, it’s our passion. When I heard the term “nurses on boards,” I immediately thought of managers and administrators. Serving on a board wasn’t something for all nurses to consider, or was it?

Leadership-competencies-for-nurses-300x750.pngA little history
According to the 2014 American Hospital Association governance data, nurses hold only 5% of board seats in health-related organizations and corporations. Shouldn’t we be involved in the decisions that affect our health care system, our organizations, our profession, our patients, and ourselves? One of the key messages of The Future of Nursing: Leading Change, Advancing Health report is “Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.” As a result of our minimal representation on governing boards and the Future of Nursing report recommendations, the Future of Nursing: Campaign for Action set a goal to get an additional 10,000 nurses on governing boards by 2020.
 
Why nurses need to “get on board”
Earlier this month, Susan Reinhard, RN, PhD, FAAN, chief strategist for the Center to Champion Nursing in America and senior vice president and director of AARP’s Public Policy Institute wrote an excellent piece, Getting nurses on board, for Trustee magazine. In her article, Reinhard addresses the gender gap and other barriers to nurses serving on boards. She also shares her path to the boardroom and the real life stories of other nurses serving on boards and how their service made an impact. For example:

“The late Connie Curran, R.N., told the story of listening as her 100-bed community hospital proposed saving money by eliminating weekend hours at its in-house pharmacy. Medication orders could be filled Friday evenings, the thinking went. The other board members, she noted, were not being negligent. But she was the only person whose experience working nights and weekends led to a few unasked questions, such as, ‘What about newly admitted patients?’ The pharmacy stayed open.”

Can you imagine working where the hospital pharmacy is closed on the weekends? This is exactly why nurses are instrumental to serving on committees, commissions, and boards where health care decisions are made. This example illustrates our unique experience and the need for us to be present where decisions are being made at the organizational level and beyond.

Overcoming barriers
As nurses, we know about overcoming barriers. We face obstacles in our day-to-day practice that force us to speak up and advocate for those in our care. In 2009, Prybil identified three barriers to nurses serving on boards:
  1. Gender – 90% of RNs in the U.S. are women and women are underrepresented on boards
  2. Belief that nurses aren’t able to weigh in on safety and quality issues
  3. Potential conflict of interest related to placing an employee in a voting capacity
How can we remove barriers and foster collaboration? Let’s focus on what we know about ourselves and our profession. First, nurses represent the largest segment of the health care workforce; there are 3.6 million of us in the United States. We are a female-dominated profession, and that should not affect our representation among the decision makers. We need to work hard to have our voices heard, and remember that we are skilled communicators and problem-solvers.

We also know the issues, especially when it comes to safety and quality care. We face these issues every day. We use the nursing process repeatedly in the clinical setting to assess, diagnose, plan, implement, and evaluate. This framework can be applied for strategically tackling any hospital-wide, local, national, or global issue. Nurses are knowledgeable and skilled and need to have a “seat at the table.”
Additionally, people trust us – that’s been proven time and again. We are on the frontlines, not only in the hospitals, clinics, and offices, but also in schools, the community, and so many other settings. And remember, we are all leaders, no matter the setting or role of our work.

The Nurses on Boards Coalition (NOBC)
The Nurses on Boards Coalition was developed to help ensure that the goal of at least 10,000 nurses are on boards by 2020 is reached. It’s a national partnership of organizations committed to this endeavor.

nobc-logo-300.png“Our goal is to improve the health of communities and the nation through the service of nurses on boards and other bodies. All boards benefit from the unique perspective of nurses to achieve the goals of improved health and efficient and effective health care systems at the local, state, and national levels.”

Visit the NOBC website to be counted if you already serve on a board, or to learn more about this initiative and board membership.
 
Wolters Kluwer is proud to be a Healthcare Leadership Organization Strategic Partner of the NOBC.
 
Improving health and wellness of U.S. citizens by placing more nurse leaders on boards
Watch this video of Chief Nurse, Dr. Anne Dabrow Woods, to learn about improving care of communities so we can improve care and outcomes for individuals. Nurses must have a voice where health care decisions are made; our unique perspective is essential to achieve optimum wellness for our patients.
This video was created for A Community Thrives (ACT), part of the USA Today Network nationwide program that provides the resources necessary for philanthropic missions in our communities to succeed.
Please consider casting your vote for this submission. You may vote once daily through May 12, 2017.
 
More Information
Nurses on Boards Coalition
Future of Nursing: Campaign for Action
American Nurses Foundation: Nurses and Board Leadership
American Nurses Association: Policy and Advocacy
References
Huston, C. (2008). Preparing nurse leaders for 2020. Journal of Nursing Management, 16(8).
Prybil, L. (2009). Engaging nurses in governing hospitals and health systems. Journal of Nursing Care Quality, 24(1).
 
 
Posted: 4/12/2017 10:47:31 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Leadership


Transmission-based isolation precautions for common pathogens

As a follow-up to our previous post on isolation guidelines, here is a list of transmission-based precautions recommended for common pathogens. 
 
Disease-specific-isolation-recommendations-500x750.png

Megan Doble, MSN, RN, CRNP
 
References:
Centers for Disease Control (CDC), 2016. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. Available at: https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm#

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee, (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
 

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Posted: 4/9/2017 5:43:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions Patient Safety


Brushing up on isolation guidelines

As the influenza season begins to subside, we can take a step back and reflect on best practices. Isolation guidelines in the health care setting continue to come up year after year as an area that brings some confusion to the clinical realm. According to the CDC, on average, 200,000 persons are hospitalized with influenza-related illnesses on an annual basis. It is imperative, therefore, that we take proper precautions to prevent the spread in the health care setting. 

Influenza is transmitted from person to person through large particle respiratory droplets which can travel up to 6 feet. Transmission may also occur via contact of infectious particles to mucosal surfaces, such as when someone coughs or sneezes in close contact or on a surface.  Thus, patients with confirmed or suspected influenza must, in addition to standard precautions, adhere to droplet precautions. According to the CDC, patients with confirmed or suspected influenza should adhere to droplet precautions for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms in the health care setting. Some health care facilities may have a specific policy requiring a longer duration of adherence to droplet precautions.

Most health care facilities have an infection control nurse or department to contact if there are any questions regarding the level of transmission-based precautions. Furthermore, the CDC offers a comprehensive reference with explicit details on preventing the spread of influenza in the health care setting.

As a review, the CDC guidelines for isolation precautions are presented in the infographics below.
(Please click infographics to view larger sizes.)
 
Isolation-Precautions-300x750.png  Transmission-Based-Precautions-300x750.png


Megan Doble, MSN, RN, CRNP
 
References:
Centers for Disease Control (CDC), 2016. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. Available at: https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm#

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee, (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

 

More Reading & Resources
Transmission-based isolation precautions for common pathogens
Evaluating Isolation Behaviors by Nurses Using Mobile Computer Workstations at the Bedside
Clinical Challenges in Isolation Care

   
Posted: 4/6/2017 9:34:16 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety


Nursing Orientation: What to know for your job search

orientation.pngGraduating from nursing school and passing your NCLEX boards is a great accomplishment and one to be very proud of, congratulations! Now you face the next step – applying and interviewing for a nursing job. This can be both exciting and stressful at the same time.

Choosing a job that has a good orientation program, however, can help lessen this stress for you. There are a few different types of orientation programs that a health care facility may offer. Understanding the different types can assist you when interviewing. Many of the terms used to describe orientation programs will vary depending on the health care facility. For instance, the health care facility may use the term preceptor program, mentor program, residency program, or nursing orientation. Most times the health care facility will include many of the same components necessary to orient you to your new role in the health care facility. It will be important for you, however, to find out what does the specific term mean to the institution you are applying to. Below, you will find the common meaning behind these terms in a typical acute care hospital setting.  

Nursing Orientation
Most hospital-based nursing orientation programs will include a general orientation in the classroom followed by an orientation on the unit you were hired to work on. The classroom will include education from each department in the hospital, as well as education on the use of the electronic medical record (EMR). The classroom orientation can vary from a few days to a few weeks depending on the health care facility. Once the majority of classroom orientation is complete, you will orient with an assigned preceptor or mentor on the unit you were hired to work on. A preceptor or mentor is a registered nurse, preferably with a BSN degree, who has been working at the institution for at least two years. The unit orientation can vary in length of time depending on the health care institution. You generally will be on orientation following your preceptor/mentor’s schedule for about three to six months. If you were hired to work in a critical care area, your orientation will most likely be longer and even up to one year depending on the facility.

Many facilities are finding it challenging to recruit experienced competent nurses to work in critical care and specialty areas, such as the Emergency Department (ED) and Operating Room (OR). To meet this challenge, many hospitals started residency programs for new nursing graduates. The residency program generally requires the newly hired nurse to attend the general nursing orientation, as well education classes on specific skills you will need to work in your area. For example, if you are hired to work in the ED or the OR, you will need education and skill competency on ECGs and Advanced Cardiac Life Support (ACLS), as well as education on other skills needed for working in that specific area.  Once the classroom training is completed and skill competency is verified you will orient in that area for a year,  possibly longer depending on the facility and your learning needs.

Many new nurses ask what if I do not feel ready to come off orientation? This is a good question; most health care facilities will extend your orientation a month to a few months depending on your learning needs.

6-questions.pngInterview questions
No matter what term the facility uses to describe their nursing orientation program there are some general questions you may want to ask when interviewing for the job. The questions include:
  • What type of nursing orientation program do you offer?
  • What type of education classes will I be taking?
  • How long will I be in orientation?
  • What support is available to me during and after my orientation?
  • Will there be one or many preceptors/mentors assigned to me during my orientation?
  • Can you provide a sample of what the orientation schedule may look like? 
It is important to remember that the health care facility wants to make your orientation a successful one. A successful orientation program helps ensure your competency caring for patients and improves both nurse recruitment and retention at the facility. You are now ready to begin the interview process, and always keep in mind why you were called to the wonderful world of nursing. Blessings :)    
 
Maureen Kroning RN MSN EdD
Nyack College School of Nursing
   
Posted: 4/3/2017 2:40:54 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Education & Career


GI Nurses & Associates Week 2017

GI Nurses & Associates Week is March 20-24, 2017!

We wish those of you in this specialty a wonderful week, and we thank you for compassion and dedication. Please enjoy the content below, specially selected to help you in your practice.

For those of us in other specialties, GI disorders can be challenging. Please explore, and share, the content in this collection with your colleagues!
 
Colorectal Cancer  
Inflammatory Bowel Disease  
Irritable Bowel Syndrome  
Clostridium difficile  
Pancreatitis   
Have a great week!

 
Posted: 3/20/2017 7:42:52 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


Elevated Lactate – Not just a marker for sepsis and septic shock

LACTATE_Short.pngAs nurses working at the bedside, most of us are familiar with the common lab test, lactate. We know that when cells become hypoxic, lactate levels increase. While working in the intensive care unit, checking a lactate level was routine. Unfortunately, an elevated lactate level is typically a bad sign for the patient, often related to increased organ dysfunction and mortality. In recent years, the blood lactate level has gained wide acceptance as an important marker in the diagnosis of sepsis and septic shock and is useful in evaluating response to fluid resuscitation. An elevated lactate is not only a marker for sepsis and septic shock – it may signal other important clinical conditions as well. So, what is lactate and what exactly does it tell us?

Lactate is an organic molecule produced by most tissues in the human body, with the highest production found in muscle.1 Here’s a quick and basic review of how lactate is produced. The body normally produces energy by way of aerobic metabolism, which requires oxygen to break down carbohydrates, amino acids, and fats. Via glycolysis, glucose is converted into pyruvate, which enters the Krebs cycle to produce oxygen and adenosine triphosphate (ATP) or energy. If oxygen isn’t available to body cells, anaerobic metabolism kicks in to produce energy. In this pathway, pyruvate is metabolized by the enzyme lactate dehydrogenase (LDH) into lactate.2 Lactate leaves the cells, enters the bloodstream, and transports to the liver, where it is oxidized back to pyruvate and then converted to glucose via the Cori cycle.1,2  Lactate is cleared from the blood, primarily by the liver and, to a lesser extent, by the kidneys and skeletal muscles.2

A normal blood lactate level is 0.5-1 mmol/L. Hyperlactatemia is defined as a persistent, mild to moderately elevated (2-4 mmol/L) lactate level without metabolic acidosis.2 This can occur with adequate tissue perfusion and tissue oxygenation. A level > 4 mmol/L defines lactic acidosis3, a level high enough to tip the acid-base balance, which may result in a serum pH < 7.35 in association with metabolic acidosis. Lactate can be measured from both venous and arterial blood.  Serum samples should be processed within 15 minutes to avoid falsely elevated results. If processing cannot occur within this time frame, the sample should be kept on ice.

Hyperlactatemia and lactic acidosis may occur with an increase in lactate production, a decrease in lactate clearance, or a combination of both.3 An increase in lactate production is typically caused by impaired tissue oxygenation, either from decreased oxygen delivery or a disorder in oxygen use, both of which lead to increased anaerobic metabolism.3 Most causes of lactic acidosis are due to significant, systemic tissue hypoperfusion, referred to as type A lactic acidosis. Alternately, in Type B lactic acidosis, the etiology may be related to toxic-induced impairment of cellular metabolism, local hypoperfusion (i.e. regional ischemia) or in many instances, the mechanism is unknown. Below are some common causes of lactic acidosis:

Type A:
  • Sepsis and septic shock: dysfunction in the microcirculation (where oxygen is exchanged) leads to lactate production, while decreased oxygen delivery contributes to a decrease in lactate clearance.3
  • Cardiogenic, obstructive and hemorrhagic shock: may cause decreased oxygen delivery and hypoperfusion.
  • Cardiac arrest: ischemia and inflammation following cardiac arrest may cause an increase in lactate.
  • Severe lung disease, respiratory failure or pulmonary edema: excessive work of breathing causes anaerobic muscle activity.
  • Trauma: hypoperfusion due to blood loss is common in trauma patients and may lead to elevated lactate levels.

Type B:
  • Seizures: depending on the type, seizures can produce a significant increase in lactate, but the effect is short-term; once the seizure has resolved, lactate levels typically return to baseline.
  • Excessive muscle activity: lactate increases with strenuous exercise due to anaerobic metabolism and may be seen in rhabdomyolysis.
  • Regional ischemia: mesenteric ischemia, bacterial peritonitis, acute pancreatitis, extremity compartment syndrome, gangrene and other types of soft tissue infections may elevate lactate.
  • Burns and smoke inhalation: smoke inhalation victims are at risk of elevated lactate due to potential inhalation of cyanide and/or carbon monoxide.
  • Diabetic ketoacidosis (DKA): due to a change in metabolism; elevated lactate in DKA is not necessarily associated with worse outcomes.
  • Thiamine deficiency: low thiamine levels result in anaerobic metabolism and increased lactate production; risk factors for thiamine deficiency include poor nutrition, chronic liver disease, alcoholism, hyperemesis gravidarum, anorexia nervosa, and gastric bypass surgery.
  • Malignancy: tumors may cause production of glycolytic enzymes, impaired liver clearance and malnutrition leading to thiamine deficiency.
  • Liver dysfunction: the liver is the primary organ responsible for lactate clearance; injury or failure results in decreased lactate clearance.
  • Genetic: inborn disorders of metabolism, particularly in the pediatric population, may cause elevated lactate levels.
  • Drugs and Toxins that may cause increased lactate:
    • Metformin (biguanide)
    • Acetaminophen
    • (Nucleoside reverse transcriptase inhibitors (NRTI)
    • Linezolid
    • Beta-2 agonists
    • Propofol
    • Epinephrine
    • Theophylline
    • Alcohols (ethanol, propylene glycol and methanol)
    • Cocaine
    • Carbon monoxide
    • Cyanide
Treatment of elevated lactate levels should be determined by the underlying cause. If hypoperfusion or hypoxemia is the culprit, focus on improving perfusion to the affected tissues. In shock, treatments include fluid administration, vasopressors, or inotropes. In regional ischemia, surgery may be needed to restore circulation or remove damaged tissue.1 If drugs, seizures, malignancy, or thiamine deficiency is the cause, stop, reverse, and treat the offending agent.1 Multiple conditions can contribute to lactic acidosis, therefore it is critical to carefully evaluate the patient’s complete medical history, conduct a thorough physical assessment, and assess other laboratory or diagnostic tests before beginning treatment.

Myrna B. Schnur, RN, MSN 

References:
1. Anderson, L.W., Mackenhauer, J., Roberts, J.C., Berg, K.M., Cocchi, M.N., and Donnino M.W. (2013, October). Etiology and therapeutic approach to elevated lactate. Mayo Clinic Proceedings, 88(10), 1127- 1140.
2. Lactic acidosis. (2017, January) Retrieved on 1/31/2017 from http://emedicine.medscape.com/article/167027-overview
3. Causes of lactic acidosis. (2017, January) Retrieved on 1/17/2017 from https://www.uptodate.com/contents/causes-of-lactic-acidosis?source=search_result&search=plasma%20lactate%20concentration&selectedTitle=1~150


More Reading & Resources
Laboratory signs of sepsis [Infographic]
The Subtle Signs of Sepsis [Infographic]
Making Sense of the Updated Sepsis Definitions
Focus On: Sepsis

 

Posted: 3/17/2017 7:59:23 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories:


Patient Safety: A personal memory and professional history

cone-164333_640.jpgIt’s Patient Safety Awareness Week, and I am reminded of an experience I had as a nursing student. My first medication error has stuck with me all these years. Why? Because like all health care professionals, as nurses, our priority is to do no harm. While not all issues related to patient safety are due to human error, we do feel a personal responsibility to ensure our patients’ safety. In today’s fast-paced health care world, that is not an easy task. While technological advances have provided a lot of support, we know that we can’t rely solely on technology – attention and collaboration, as well as speaking out about our experiences, are key.

In February of 2017, Nursing's Evolving Role in Patient Safety was published in American Journal of Nursing. This content analysis documents the history of patient safety related to nursing care, as illustrated by articles published in the journal. What an interesting study demonstrating the importance of our role in keeping patients safe through the years. The analysis dates back to the first issue of AJN in October of 1900! Go ahead and give this a read – you’ll see just how much has changed and, equally important, how much has stayed the same. 

 
Posted: 3/14/2017 10:57:17 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


Laboratory signs of sepsis [Infographic]

Patients with sepsis can present in a variety of ways making sepsis very difficult to diagnose. Clinicians are now encouraged to use tools, such as the Sequential (Sepsis-Related) Organ Failure Assessment Score (SOFA), to assist in screening for septic patients. In addition to the parameters outlined in the SOFA score (hypoxemia, blood pressure, platelets, bilirubin, creatinine, urine output, and Glascow Coma Scale), several other laboratory values may help identify patients at high risk for organ failure and sepsis.

Use this infographic as reference guide for lab results that you may see in septic patients.

Myrna B. Schnur, RN, MSN  
Reference:
Neviere, R. (2017, February 28). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis. Retrieved from UpToDate: https://www.uptodate.com/contents/sepsis-syndromes-in-adults-epidemiology-definitions-clinical-presentation-diagnosis-and-prognosis
Laboratory-signs-of-sepsis_300x750.png

 

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Posted: 3/11/2017 5:09:52 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions


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