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Evidence-based strategies for managing trauma and its complications in this population.
Overview: Trauma is the seventh leading cause of death in older adults. Factors that contribute to the higher rates of morbidity and mortality in geriatric trauma victims include age-related physiologic changes, a high prevalence of comorbidities, and poor physiologic reserves. Existing assessment and management standards for the care of older adults haven't been evaluated for efficacy in geriatric trauma patients, and standardized protocols for trauma management haven't been tested in older adults. Until such specific standards are developed, nurses must be guided by the relevant literature in various areas. The author reviews the mechanisms of traumatic injury in older adults, discusses the effects of aging and comorbidities, reviews assessment guidelines and prevention strategies for trauma-related complications, and outlines some evidence-based approaches for improving outcomes. An illustrative case is also provided.
Keywords: geriatric trauma, hospitalized older adults, older adults, trauma, traumatic injury
The "graying" of America is no secret; most of us have heard some version of the statistical projections. In 2010 the U.S. population of older adults-people ages 65 and older-stood at about 40 million; by 2030, their numbers are expected to nearly double to more than 72 million.1, 2 Most nurses are aware that working with older patients poses some challenges not encountered as often with younger patients. Older adults have a higher rate of comorbidity and routinely take more medications than do younger ones, and they're more likely to have unpredictable responses to treatment and to suffer adverse events during hospitalization.3
Trauma is the seventh leading cause of death in older adults.4 Although older adults now constitute about 13% of the total U.S. population,5 they account for more than 25% of all hospital trauma admissions,6 and it's likely that as the proportion of older adults rises, that percentage will also rise. Indeed, it's been estimated that by 2050, about 40% of all trauma patients will be over age 65.6, 7 Falls are known to be the leading cause of injury in older adults. Other common causes of injury in this age group include motor vehicle collisions, pedestrian-motor vehicle collisions, assault, and thermal injuries. For any injury of a given severity level, older adults are more likely to suffer complications and die than are younger ones.
These statistics and projections are alarming, not only because of the personal costs to patients and families, but also because of the financial impact on our health care system. For example, in 2000 McMahon and colleagues reported that the geriatric population consumed 33% of U.S. health care spending and 25% of all trauma dollars.8 A 2008 report by the American College of Emergency Physicians (ACEP) noted that although older adults represent 15% of all patients seen in EDs, they account for 48% of ICU admissions and use 50% more diagnostic resources.9 Such disproportionate usage of resources is also likely to become greater as the population ages. It behooves us to examine what is being done-and to ask what more can be done-to address these trends.
While advanced age is associated with increased risks of morbidity and death,4, 10 it's not an independent predictor of trauma outcome and "should not be used as the sole criterion for denying or limiting care."4 One early study of geriatric trauma patients found that preventable complications contributed to over 30% of all deaths11; but more recent studies attribute many post-trauma complications to preexisting conditions and age-related physiologic changes.10, 12 Regardless, hospitalizations for trauma are often prolonged, and recovery delayed, by many of the same iatrogenic complications addressed by the Institute of Medicine (IOM) in its 1999 report, To Err Is Human: Building a Safer Health System. These include adverse drug events, falls, pressure ulcers, inadequate nutrition, incontinence, and delirium, and they contribute to unfavorable outcomes for hospitalized older adults. They are so common in this population that they're becoming known as "geriatric syndromes."13
What guides current care? The American Geriatrics Society (AGS) has proposed wider, standardized use of comprehensive geriatric assessment for older adults at each entry into the health care system.14 The American College of Surgeons (ACS) and the ACEP have advocated the development of evidence-based clinical protocols and pathways for both acute care and ongoing management of geriatric patients.9, 15 These protocols and pathways will undoubtedly draw upon many of the assessment and treatment standards implemented through the well-established Nurses Improving Care for Healthsystem Elders initiative (http://nicheprogram.org). But although such standards for geriatric patients have been developed, they've yet to be evaluated for efficacy with those suffering from traumatic injury. And although several standardized protocols for trauma management exist, they were developed primarily for younger patients and haven't been tested in older adults. Thus, until assessment and management standards specific to geriatric trauma patients are developed and widely implemented, nurses will need to be guided by measures known to prevent iatrogenic complications in other patient populations.
This article reviews the mechanisms of traumatic injury in older adults, discusses the effects of aging and comorbidities, reviews assessment guidelines and prevention strategies for trauma-related complications, and outlines some evidence-based approaches for improving outcomes in geriatric trauma patients. A patient case is also provided (see An Illustrative Case).
Terms defined. Although various lay definitions exist, this article uses the definition of serious injury or trauma as stated by Richmond and colleagues: "the anatomical and physiological derangements induced by the application of external physical forces to the body, resulting in injuries that threaten limb loss or death."10Older adults here refers to people ages 65 or older; geriatric patients refers to patients in that age group.
Why is trauma so much more "traumatic" for older people? Factors that contribute to the higher rates of morbidity and mortality in geriatric trauma victims include age-related physiologic changes, a greater prevalence of comorbidities, and poorer physiologic reserves.
Physiologic changes associated with normal aging can predispose some older adults to serious injury and make recovery of function less likely.8, 16 For example, advancing age is associated with diminished vision and hearing, slower reflexes, and poorer balance. Older adults also tend to have more mobility limitations, reduced muscle mass and strength, and less joint flexibility. Age-related changes in bone density and decreasing lean muscle mass can make bone fractures more likely, with hip fracture being the most prevalent.
Comorbidities are very common in older adults. Approximately 80% of people ages 65 and older have one or more chronic diseases17; the most common include hypertension, arthritis, heart disease, cancer, diabetes, stroke, asthma, and chronic bronchitis or emphysema.2 And comorbid illness is more often the initiating event for trauma in older adults than it is in younger ones.8
Older adults generally have poorer physiologic reserves and are less able to maintain homeostasis, resulting in poor temperature control and less ability to maintain fluid and electrolyte balance.3, 18 Once they're injured, compensatory responses may be inadequate to stabilize older adults physiologically. Changes in vital signs are less reliable indicators of instability. For example, in a person with chronic hypertension, a seemingly normal blood pressure reading may actually be indicative of hypotension. The "fight or flight" responses associated with injury are less robust in older people. Compensatory increases in heart rate may be impossible if the patient has an implanted pacemaker. The normal tachycardic response to injury may be blunted or diminished in patients with chronic cardiac arrhythmias, such as atrial fibrillation. Although an older adult with atrial fibrillation might be able to achieve adequate tissue perfusion under ordinary circumstances, a traumatic injury can overwhelm the person's compensatory abilities. Tissue hypoxia can in turn cause other arrhythmias, such as premature ventricular contractions, that can further alter cardiac output. This cycle of tissue and organ hypoxia can have predictably negative effects.
Poorer physiologic reserves can be exacerbated by the drugs taken to manage comorbidities. For example, [beta]-blockers, which are used to manage various conditions including hypertension and cardiac arrhythmias, directly alter physiologic responses to shock. Clinicians often rely on tachycardia as an indicator of physiologic distress; but this warning sign can be masked by [beta]-blockers, which slow the heart rate. In my career in critical care nursing, I've had numerous experiences in which a patient on [beta]-blockers was bleeding internally but didn't develop tachycardia and thus didn't receive early intervention. Bleeding may not become evident until tissue hypoxia has already resulted in considerable damage to end organs. This can be especially dangerous when the bleeding is retroperitoneal or intracranial, where it isn't as evident as bleeding elsewhere. Large amounts of blood can collect in the retroperitoneal space with few outward signs other than back pain. A high index of suspicion is required for the recognition of retroperitoneal bleeding, especially in patients on [beta]-blockers.
Similarly, the development of traumatic subdural hematomas can also escape timely recognition. Many older adults take warfarin (Coumadin), an anticoagulant, for various conditions including atrial fibrillation. The normal physiologic atrophy in an aging brain creates more intracranial space; in a trauma patient, significantly more blood can accumulate before symptoms become evident.19 Delayed recognition of the deterioration of such patients will lead to predictably negative outcomes.
Undertriage. Optimum management of any trauma patient involves expert field stabilization, minimal transport time, and triage to the appropriate level of trauma care. But complicating the management of geriatric trauma patients is undertreatment both at the scene and in the ED.9 Studies that have looked specifically at undertriage-defined as "when trauma patients were not transported to a state-designated trauma center"20-have found that older patients are consistently less likely to be so transported.20, 21 One study found that undertriaged geriatric trauma patients had four times the mortality and discharge disability rates of undertriaged younger patients.22 Based on these and other outcome studies, the ACS now recommends that trauma patients over the age of 55 be transported to trauma centers based on that criterion alone.15
Regardless of patient age, trauma care priorities don't change. Initial assessment and resuscitation efforts follow the "ABCs": airway, breathing, and circulation. What distinguish geriatric trauma victims from younger ones are their generally poorer physiologic reserves and the greater likelihood of comorbidities. It's important to remember that individual health status varies markedly, even for patients of the same age. That said, age-related physiologic changes are likely to affect the various body systems to some degree. The complications associated with those changes are more common in older people than in younger ones. It's beyond the scope of this article to review the effects of all major trauma conditions on all body systems; rather, the focus will be on what distinguishes geriatric trauma victims from younger ones and what endangers them more. (For a list of some common age-related physiologic changes and associated complications, see Table 1.3, 18, 23)
Airway and breathing. In all trauma patients, the cervical spine is first stabilized and then assessed for possible injury. Since many older adults have osteoporosis, which makes them more susceptible to fractures, extreme care must be taken in stabilizing an older patient's spine. Age-related loss of muscle mass and strength may also contribute to weaker gag and cough reflexes. This makes it harder for the older patient to clear her or his airway, increasing the risk of aspiration. The use of suction, which increases intrathoracic (and therefore central venous) pressure and can exacerbate bleeding, should be kept to a minimum, both in the amount of negative pressure used (since an older person's tissues are more delicate) and in duration (since it suctions out oxygen as well). It should also be kept in mind that suctioning can cause coughing and gagging, which can also raise intrathoracic pressure. If there is any chance that the cribriform plate-the cartilage separating the nose from the brain-has been damaged, neither suction nor intubation can be attempted nasally. Prophylactic intubation may be necessary if there's any indication (such as decreased level of consciousness or diminished gag reflex) that the patient can't maintain her or his airway. The standard is to administer oxygen to any trauma patient with apparent significant injury.24 Although denture removal is also a standard airway-protective measure, this will make it harder to achieve a good seal with a bag-valve-mask device.
The chest wall becomes less compliant and the lungs less elastic with advancing age. In a patient with broken ribs or pulmonary injuries, the work of breathing can be just that: work. It's important to note whether a patient is tiring from the effort to breathe, even if oxygen saturation levels are normal. The effort to breathe may not be sustainable; and if pain is present, it may be nearly impossible for the patient to maintain adequate ventilation, increasing the risk of atelectasis. Because pain medications can depress respiration, the use of analgesia may require a pain consultation.
Once adequate ventilation is assured, measures to prevent atelectasis and pneumonia are essential. Measures to prevent atelectasis may include elevation of the head of the bed (unless contraindicated), incentive spirometry, and early ambulation. Older patients on ventilators and positive end-expiratory pressure are especially prone to complications of barotrauma, such as pneumothorax and decreased cardiac output; and those with malnutrition or age-compromised immune systems are at higher risk for ventilator-associated pneumonia (VAP). Additional measures to prevent VAP include early extubation, frequent oral care, and peptic ulcer and deep vein thrombosis prophylaxes. (For more on preventing VAP, visit http://www.cdc.gov/HAI/vap/vap.html).
Circulation. For any trauma patient, fluid resuscitation begins with IV administration of crystalloid solutions, either Ringer's lactate or normal saline. Typically one to two liters are given initially; if more volume is needed, packed red blood cells are considered. (Most adults have four to five liters of blood, so if replacing essentially half the person's blood volume with crystalloids isn't effective, it's time to consider blood and blood products.) Any additional fluid challenges may need to involve smaller volumes and more frequent assessment; but maintaining adequate circulatory volume is imperative. Inadequate perfusion in a geriatric trauma patient can lead to myocardial ischemia or infarction. Since heart rate and blood pressure may not be reliable indicators of an older patient's stability, frequent evaluation of hematocrit and hemoglobin levels, lung sounds, urine output, oxygen saturation levels, and capillary refill time can all be valuable, especially in the absence of more sophisticated hemodynamic monitoring. Most clinicians who are experienced in trauma care are acutely aware of the challenges of keeping a patient hydrated while avoiding fluid overload.
The importance of frequent assessment of hematologic status cannot be overemphasized, especially in patients with multiple fractures or crush injuries. In such cases, bleeding can continue for more than 24 hours, and over time a patient can bleed one to two units into and around each fracture. Cardiac arrhythmias must be evaluated, as they may be associated with injury, electrolyte imbalance, or preexisting cardiac disease, and may signify a worsening condition. In patients with critical injuries, blood lactate and base levels are frequently monitored. These values are considered more accurate for detecting metabolic acidosis than monitoring blood bicarbonate alone. A base deficit is indicative of inadequate tissue oxygenation and is associated with significantly higher mortality.25
Lastly, although temperature isn't one of the ABCs, it's a crucial consideration in initial trauma care. Trauma patients are undressed for examinations, often given solutions at room temperature, and kept on relatively cold trauma stretchers, sometimes for extended periods. Hypothermia places older patients at higher risk for several temperature-related complications, among them premature ventricular contractions and ventricular tachycardia. Hypothermia also slows oxygen delivery to the tissues. Using heated blankets and warming IV solutions and blood products becomes more vital the longer the resuscitation efforts last.
Once the ABCs are assured, a secondary, head-to-toe assessment is performed. This is done to identify and evaluate any injuries that aren't immediately apparent or life threatening, with the goal of preventing further disability. Additional tests may also be needed, depending on the type and mechanism of injury found and other assessment findings. Even with the advanced technologies available today, injuries can be missed; ongoing nursing vigilance is essential. The issues that are recognized and addressed as a result of this secondary assessment can have considerable impact on the patient's eventual outcome. The following is a system-by-system look at some of these issues.
Neurologic. Cognitive impairments may have precipitated the traumatic injury, result from it, or both. A change in level of consciousness is the first symptom of deterioration in cases of traumatic brain injury, regardless of the patient's age. It may manifest as confusion, agitation, somnolence, or a combination of these. But these same symptoms can be the result of an entirely different problem, such as pain, and should be differentiated. Patients with suspected traumatic brain injuries should not be allowed to sleep for long periods and must be assessed frequently. Confusion, especially in older adults, requires close monitoring and frequent reorientation. Restraints should be used only as a last resort to ensure patient safety. Their use can be frightening to patients who might not remember receiving an explanation for why they're necessary, and can cause further agitation. If restraints are absolutely necessary, in my experience, patients with traumatic brain injuries seem to find vest or mitt restraints less objectionable than more restrictive limb restraints.
Renal. Age-related decreases in the glomerular filtration rate can wreak havoc in the geriatric patient. Renal clearance can deteriorate further as a result of hypoxemia, nephrotoxic drugs (such as aminoglycosides, diuretics, contrast media, and others), or age-related slower drug metabolism. Drug dosage adjustments may be indicated and drug levels should be checked periodically, especially for drugs with long half-lives. Intravenous contrast media can precipitate severe fluid and electrolyte imbalances or even acute renal failure in a geriatric trauma patient. Careful follow-up is required in such cases. In older patients with kidney injuries, a high index of suspicion for retroperitoneal bleeding is called for.
Diabetes insipidus may result from traumatic brain injury: damage to the posterior pituitary gland can disrupt secretion of antidiuretic hormone (ADH, also called vasopressin), resulting in severe diuresis and fluid and electrolyte imbalances. Management requires fluid and electrolyte replacement therapy and treatment with synthetic vasopressin (Pitressin) to replace ADH.
Gastrointestinal. Maintaining adequate nutrition can be a consistent and challenging problem with older trauma victims. In general, older adults often have decreased appetites, reduced metabolism, and decreased colonic motility; these factors as well as the presence of comorbidities can put them at higher risk for under or malnutrition. They are thus prone to complications such as compromised immune function, slow wound healing, and loss of skin integrity. Many ICUs now monitor serum prealbumin, rather than albumin, as it is a much better indicator of nutritional status.26 Research supports giving early enteral nutrition to trauma patients whenever possible, as this helps offset stress-induced hypermetabolism, helps to maintain the gut's mucosal integrity, and minimizes bacterial entrance into the portal and systemic circulation.27, 28
Consultation with a dietician and incorporating nutritional measures into the plan of care are also essential in such cases.
Musculoskeletal and integumentary. Advancing age is associated with loss of muscle mass and strength; and many older adults, especially women, also have osteoporosis, a skeletal disease characterized by low bone density and strength. These conditions put older adults at higher risk for bone fractures. In geriatric trauma patients, once a fracture has been diagnosed, further assessment of the "zone of injury"-an area including the joints immediately above and below a fracture-is necessary. Certain fractures are often concomitant with others; for example, hip fractures resulting from a fall can be associated with wrist or shoulder fractures incurred when the person tries to break that fall. Upper-extremity fractures can be particularly devastating for older adults, impairing their ability to care for themselves and manage activities of daily living. Discharge planning should include assessment of bone density and balance. A home environment evaluation might also be helpful in preventing future injuries.
All fractures can result in bleeding and edema in a closed area; patients with fractures require assessment for compartment syndrome. The resulting pressure and neurovascular compromise can result in one or more of the five "Ps": pain, pallor, paresthesia, pulselessness, and paralysis. Splitting the cast, if the area is casted, or performing a fasciotomy may be necessary to relieve the pressure. Crush injuries in particular are known to cause compartment syndrome and these can also result in myoglobinuria and subsequent renal failure.
The skin of older adults tends to damage easily and to heal slowly. Certified wound care nurses, if available, can assist with managing skin-related complications in geriatric trauma patients. There are evidence-based treatments for most kinds of skin damage, including pressure ulcers and shear injuries.
Older adults who suffer thermal injuries are at much higher risk for long-term disability and death than are younger ones.29 Inhalation burns should be suspected in patients with facial burns and singed nasal mucosa or soot in the nares. Carboxyhemoglobin levels must be assessed when a burn was incurred in an enclosed area. Burns are complicated systemic injuries requiring management by experts. The American Burn Association's criteria for transferring a patient to a burn unit include the following30:
* first- or second-degree burns over more than 10% total body surface area
* third-degree burns
* inhalation injury
* chemical or electrical injury
* burns with associated trauma
* burn injuries in patients with any preexisting comorbidities (such as diabetes, hypertension, chronic obstructive pulmonary disease, heart failure) that might complicate management
* burns of the hands, face, feet, genitalia, perineum, or major joints
There are several initial fluid resuscitation formulas for burn victims in the literature, of which the Parkland formula (http://www.mdcalc.com/parkland-formula-for-burns) is probably the best known. Most use body weight and burn surface area in calculating the amount of fluids to infuse over a 24-hour period. However, no existing formula takes advanced age into account.31 There's evidence of a trend toward using end-point monitoring (of end points such as urine output and blood pressure) and administering fluids to keep these within target ranges.32 This might help prevent complications that can result from using standard treatments in geriatric trauma patients. For example, an older adult with chronic heart failure and a traumatic injury could be propelled into fluid overload by a typical rapid fluid challenge of 500 to 1,000 mL; assessing that patient's lungs after each bolus of 250 mL is probably a safer management strategy.
As the proportion of older Americans increases, simply being aware of how older trauma victims differ from younger ones and practicing vigilant care may not be enough to prevent us from being overwhelmed by their numbers. If we subscribe to the philosophy of the trauma care community that most trauma is preventable, then we must ask what more can be done. Upon discharge, many patients will be returning to the same environment in which the traumatic injury occurred-or possibly to one even less safe. Experts have recommended interdisciplinary care for geriatric trauma patients that involves ongoing assessment and management from admission through discharge, and even afterward, if possible. (As with any patient, it's essential to involve family members and friends in these matters as well.) Some successful measures have been identified for broader implementation and further study.
The recommendations of the AGS, the ACS, and the ACEP center around three broad categories: early screening for all high-risk older patients; prevention and early recognition of complications; and interdisciplinary discharge planning.9, 14, 15, 33 Many of the recommendations in each category are already standard current nursing practice, although not necessarily specific to geriatric trauma patients.
Nursing's role in proactive intervention is well documented. Falls risk assessment, skin assessment, promotion of early ambulation, incentive spirometry, and measures to prevent nosocomial infections (such as urinary tract infections, ventilator-associated pneumonia, and central line-related bloodstream infections) are patient safety measures now expected by regulatory agencies like the Joint Commission (and some are also nursing-sensitive quality indicators). As evidence-based clinical protocols and pathways for both acute care and ongoing management of geriatric trauma patients are developed, such measures will undoubtedly be included. Education of nursing staff and quality-of-care monitoring will also be needed to ensure compliance.
Overall, the importance of nursing to the prevention of complications in and the improvement of functional outcomes for hospitalized older adults has been established. However, experts have recommended further research specific to older victims of trauma.10, 12, 34 Areas in which more study is warranted include early mobilization, assessment of cognition, prevention of respiratory complications, assessment of nutritional status, pain control, attention to sleep disturbances, fall prevention, and skin integrity. More physiologic studies are also needed. One study examined oxygen debt in adult trauma patients in a surgical ICU, and confirmed that older patients had significantly lower levels of oxygen delivery and consumption.35 The researchers called for further study on how the pacing and adjustment of nursing interventions should be modified for older trauma patients. In my experience, the use of nursing judgment to assess patient status and determine timeliness of treatment is routine. For example, in patients with head trauma, when possible, the nursing staff would suspend or delay any treatments (such as suctioning) that might result in sustained increases in intracranial pressure.
Some promising results. One large study at an urban trauma center investigated whether admission to the step-down unit, which offered increased patient monitoring and low patient-to-nurse ratios, affected the outcomes of 255 geriatric patients with hip fractures.36 National mortality rates for such fractures in older adults reportedly range from 6% to 30%; at this trauma center, the mortality rate had previously been 20%. But the study found that with admission to the step-down unit, mortality fell to 2%. Although the researchers didn't specifically examine nursing measures, they pointed to research by others demonstrating "that high patient-to-nurse ratios translate to higher risk-adjusted 30-day mortality for surgical patients."36, 37
Others have studied interventions aimed at improving outcomes in geriatric patients and, in the case of trauma victims, restoring them to preinjury status. A systematic review considered the evidence for interventions designed to improve outcomes in geriatric patients after ED discharge.38 These included using telephone follow-up, using an ED team trained in geriatric assessment, performing functional assessments before discharge, making greater use of home care services, and providing better education to ED staff. Another group of researchers developed a standardized geriatric consultation for patients admitted to a trauma service; this evaluated the patient's pretrauma social situation, clinical condition, physical and cognitive function, mood (depression), use of potentially inappropriate medications, and control of pain.39 In another study of hospitalized older adults, investigators studied the effectiveness of an advanced practice nurse (APN)-centered discharge planning and home follow-up intervention.40 They found that the intervention led to lower readmission rates, longer times between discharge and readmission, and decreased costs of care. Given the projected shortage of 25,000 gerontologists by 2030,9 this successful use of APN-centered care for at-risk older adults seems particularly promising.
In its 2008 report Retooling for an Aging America: Building the Health Care Workforce, the IOM reported that the proportion of recommended care that patients receive decreases with age, and recommended a new health care model to address the challenges of an aging population.41 Although not specific to geriatric trauma patients alone, the report's findings and recommendations are certainly relevant here. The IOM's proposed model includes more education for all disciplines involved in the care of older adults, including emergency responders and nurses. The report noted that only a third of baccalaureate nursing programs require a course in geriatrics and that less than 1% of RNs are certified in geriatrics.41 Other recommendations include interdisciplinary team care, transitional care as patients move between health care settings, proactive rehabilitation, pharmaceutical management, and preventive home visits. Given the critical role nurses play in the assessment and management of geriatric trauma patients and the prevention of iatrogenic complications, better educational preparation for nurses in these areas is essential.
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41. Institute of Medicine Committee on the Future Health Care Workforce for Older Americans, Board on Health Care Services. Retooling for an aging America: building the health care workforce. Washington, DC: National Academies Press; 2008. http://www.nap.edu/catalog.php?record_id=12089. [Context Link]
For 72 additional continuing nursing education articles on geriatric topics, go to http://www.nursingcenter.com/ce.
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Caring for...Patients of different religions
Nursing Made Incredibly Easy!, November/December 2014
Expires: 12/31/2016 CE:2 $21.95
Autoimmune disease: Cost-effective care
Nursing Management, November 2014
Expires: 11/30/2016 CE:1.5 $17.95
CE: Original Research: Staff Nurses' Perceptions Regarding Palliative Care for Hospitalized Older Adults
AJN, American Journal of Nursing, November 2014
Expires: 11/30/2016 CE:2.5 $24.95
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Dogs as Pets, Visitors, Therapists and Assistants
Home Healthcare Nurse, November/December 2014
Free access will expire on January 5, 2015.
Nursing2014 Critical Care, November 2014
Free access will expire on December 22, 2014.
Effective management of ARDS
The Nurse Practitioner, 13December 2014
Free access will expire on December 22, 2014.
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