Intro Critical Care Nursing Ex Med Ed

8/19/2019 Intro Critical Care Nursing Ex Med Ed

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Med-Ed, Inc * 1911 Charlotte Drive * Charlotte * North Carolina * 28203 * p (704) 333-1090 * f (704) 333-5020 * www.mededseminars.net

©Copyrighted Materials, All Rights Reserved

Nursing EXcellence TrainingOnline Orientation Program

Introduction to Critical Care Nursing Module Presented by: Cammy House-Fancher, ACNP, MSN, CCRN-CSC, PCCN

Topic DescriptionThis introduction begins a comprehensive review of the core concepts required by the bedside critica

care nurse. The focus of this module is to prepare the novice critical care nurse to provide patient-centered, quality care in the complex environment of the intensive care unit. Presentations correlate

evidence-based practice guidelines, the “Institute of Health’s Improvement” Initiatives to “Save 100,000

Lives” and “Do No Harm”, and AACN’s concepts of a healthy work environment.

Chapters1. Evidence Based-Practice2. Healthy Work Environment

3.

Daily Goal Checklist4.

Save 100,000 Lives5. Do No Harm

Objectives At the completion of this topic, the participant will be able to:

1. Incorporate principles of critical care nursing, the synergy model and evidence-based practice to

provide a healthy work environment and improve patient outcomes.2.

Analyze common critical care health problems and their treatment modalities.3. List, discuss and utilize treatment modalities to prevent complications of critical illness.

4. Improve communication and collaboration with peers and colleagues responsible for patient care.


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Introduction toCritical Care Nursing

Med Ed

2009

Objectives

1. Discuss and define the hospital’s

mission of care for the critically ill

adult. 2. Incorporate principles of critical

care nursing, the synergy model and

evidence based practice (EBP) to

provide a healthy work environment

and improve patient outcomes.

Nursing EXcellence Training (NEXT) - Introduction to Critical Care Nursing Module

Presented by: Cammy House-Fancher ACNP, MSN, CCRN-CSC, PCCN

1911 Charlotte Drive Charlotte, North Carolina 28203T 704-333-1090 * F 704-333-5020 * www.MedEdSeminars.net * [email protected]

Copyrighted by Med-Ed, Inc., All Rights Reserved

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Objectives

3. Analyze common critical carehealth problems and their treatment

modalities.

4. List, discuss and utilize treatment

modalities to prevent complications of

critical illness.

Objectives

5. Improve communication and

collaboration with peers and

colleagues responsible for patient

care.

Critical Care

Major changes have occurred in every

aspect of health care delivery

Focus of the nurse has expanded from

direct patient care to organizing anddelivering EBP patient-centered care

with multiprofessional collaboration to

optimize patient outcomes within a

managed care environment…….





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Focus

Integrating sophisticated technologywith psychosocial challenges and

ethical conflicts associated with

critical illness.

Patient and Family Centered

“Humanized’ Care

Changes

Pt acuity

Safety risks

Reduced stay

New technology

Nurse shortage

Cost reduction

Total qualitymanagement

Managed care

New devices

New regulations

EBP

Emphasis on outcomes, cost-

effectiveness, and consumer

satisfaction





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EBP

“improving the quality of healthcarerequires a commitment to delivering

healthcare based on sound scientific

evidence and continuously innovating

new, effective healthcare practices

and preventive approaches..” President’sAdvisory Commission on Consumer Protection and

Quality in Healthcare

Steps to EBP Critical Care

Nursing Accept change

Exam pt outcomes

Causes of

dissatisfaction

Frame a clinical

question and searchliterature

Scientific merit

Conduct comparisonof current practiceand current

research

Implement change

Measure progress

Measure progress

Measure progress

Critical Thinking

Panel of experts: 10 affective habits of the

mind and 7 cognitive skills, components of

critical thinking 10 habits

Confidence, Contextual Perspective,

Creativity, Flexibility, Inquisitiveness,Intellectual Ability, Intuition, Open-

Mindedness, Perseverance, and Reflection





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7 Cognitive Skills

Analyzing, Applying Standards,

Discriminating, Information Seeking,

Logical Reasoning, Predicting, and

Transforming Knowledge

Critical Thinking 101

Traditional teaching--Does Not Work

Strategies

Case Study Format, simulation,

videotaped vignettes, role playing,

clinical questioning

Mentors, Role Model

“Tinciture of Time”

Novice To Expert

Clinical Experience and Time





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Synergy Model

AACN’s Model

1999

Link certified practice to clinical

outcomes.

Working Together

Common Goal

Patient - Nurse Link ??

What Drives the System





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Transform Your Practice

Daily





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Patient SafetyBest Bedside Practice

Cammy House-Fancher, ACNP,MSN, CCRN-CSC, PCCN

University of Florida

Patient Safety

• BEST Practice

• Bring Up the Bar

• Kick It Up a Notch

• Make It Happen

• Culture of Excellence

CULTURE OF EXCELLENCE

• AACN’s promotes creation of HWE

• HWE supports and fosters excellence in

patient care• Committed to promoting excellence in

patient care





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COMPONENTS OFEXCELLENCE

• EDUCATION

• COMMITMENT

• ENVIRONMENT

EVIDENCE BASEDPRACTICE

• “Conscientious application of scientifically bestpractice by clinician in concert with patientunderstanding and valves”

• “Science of Medicine”

• “The integration of individual clinical expertise withthe best available external clinical evidence fromsystematic research” “ Art ofMedicine”

CDC: RATING THEEVIDENCE

• Category IA: strongly recommended forimplementation based on well-designed

clinical studies• Category IB: strongly recommended for

implementation based on clinicalstudies or theoretical rationale

• Category IC: required by state orregulatory agencies





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CDC

• Category II: suggested for implementationbased on clinical studies or theoreticalrationale

• Unresolved issue: evidence is insufficient orno consensus regarding efficacy

» CDC 2003 Guidelines for Prevention of Healthcare Associated Pneumonia: MMWR;2004:53(no RR-3)

BEST CARE PRACTICES

• Build value into the structure

• Build value into the practice ofevidence-based practice--Medical andNursing

• Can Not change behaviors without“owning” the practice

• The value is inherent in evidence

BUILDING A PRACTICE OFEXCELLENCE

THROUGHKNOWLEDGE





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EXCELLENCE

• Building Environment• Decreasing errors

• Increasing Patient Safety

• Checklists

10 TIPS TO IMPROVE CAREIN YOUR ICU

1. Conversation: www.sccm.org/tips

2. Improve Nursing Through Certification

3. Improve Skills of the Non-ICUSpecialist: FCCSCourse

4. Standardize ICU Practice: Evidence BasedGuidelines

5. Reduce Medication Errors

10 TIPS TO IMPROVE CAREIN YOUR ICU

6. Improve the Physical Environment

7. Measure Your Progress

8. Be More Visible

9. Advocate for Better Care

10. Implement a MultiprofessionalTeam Approach





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WHAT ARE WE TALKING ABOUT

• Creating the case for HWE• Overview of the AACN Standards

• “Painting a picture” of HWE using theStandards and critical elements

HWE

• Mounting evidence that unhealthy work environmentscontribute to medical errors, ineffective delivery ofcare, and conflict and stress among healthprofessionals.

• Create healthy work environment to ensure patientsafety, enhance staff recruitment and retention, andmaintain an organization’s financial viability.

HWE: TWO STRATEGICPLATFORMS

• 1. Work and care environments mustbe safe, healing and humane, respectful

of the rights, responsibilities, needs andcontributions of patients, their families,nurses and all health professionals.





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• 2. Excellence in acute and critical carenursing practice is driven by the needsof patients and their families and isachieved when nurses’ competenciesare matched to those needs.

MY GOALS

• IMPROVEMENT OF PATIENTOUTCOMES: WHERE IS THE EDGE

• Challenge your thinking

• Make you uneasy

• Move you to action

ASSERTION # 1

• There is a direct link between workenvironment and patient safety

• Ergo, if you are not addressing yourwork environment, you are not

addressing patient safety…





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• “The mistakes are all there, waitingto be made”

– Chess master S. Tartakower (1887-1956)

ASSERTION # 2

• Healthy work environments do not justhappen

• Ergo, if you do not have a formalprogram in place addressing work

environment issues, little will change

• “Organizations learn and evolve throughconscious, deliberate action. Deliberate

action is ethical. When the time to acthas come, it is unethical not to dosomething.”

» David Thomas

» Ethics of Choice





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ASSERTION #3

• Creating healthy work environments requireschanging long-standing cultures, traditionsand hierarchies

• Ergo, while everyone must be involved in thecreation of healthy work environments, theonus is onorganizational/departmental/unit leadersto assure that it happens

• “To do more than the minimum inanything takes leadership…”

» Robert Wachter

» 2004

THE ASSERTIONS

• HWE’s are directly linked to patientsafety

• HWE’s require a formal program

• Leaders must drive HWE’s





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AACN’S STANDARDS

• The standards represent evidence-based and relationship-centeredprinciples of professional performance.

• Align directly with core competenciesIOM.

STANDARDS

• NEW WORDS

• Outcomes, Evidence-Based Practice,RCT, Patient Centered Care, E ICU,Informatics

• Patient Driven Care

• Daily Goal Sheets

AACN’s STANDARDS

• MEANINGFUL RECOGNITION

• Nurses must be recognized and mustrecognize others for the value eachbrings to the work of the organization





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AACN’s STANDARDS

• AUTHENTIC LEADERSHIP

• Nurse leaders must fully embrace theimperative of a healthy workenvironment, authentically live it andengage others in its achievement

CREATING THE CASE FORHWE’s

WHAT DO WE KNOW????

STANDARDS

• Skilledcommunication

• TrueCollaboration

• Effective decisionmaking

• AppropriateStaffing

• MeaningfulRecognition

• AuthenticLeadership





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• Communication issues arepresent in 65% of all sentinelevents reported to JCAHO

COMMUNICATION ISSUES

• Are present in more than 75% of wrongsite surgeries and delays in treatments

• And they are present in more than 60%of medication errors and ventilator“events”

SKILLED COMMUNICATION

• Focus on finding solutions

• Protect relationships

• Hear all perspectives

• Good will and mutual respect• Congruence between words

& actions

• Zero-tolerance

• Formal structures

for communication• Access totechnology

• Evaluation

• Part of performanceappraisal





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Skilled Communication

• “Stories vs Facts”

• Collaboration • More than 90% havewitnessed disruptivebehavior by MDs

• Aware of actual adverseconsequences

• 17-30% nurses leave

• High prevalence of disruptivebehavior among nurses

TRUE COLLABORATION

• Nurse managers and medical directorsare equal partners in modeling and

fostering true collaboration.• Unresponsive bureaucracy generates

organizational stress=nurse burnout





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CREATING THE CASE

Are There Challenges???

CHALLENGES TO THECASE

• Links to patient safety are notuniversally recognized

• Relationship issues seen as “soft”

• Hierarchy and power structures

• Hard to measure improvements

• Tradition

• Not a “sexy” issue

In the $1.5 trillion US health caresystem

• “Hospitals, like any other business, need tobe accountable for providing services thatdon’t harm the people they serve”

» R. Bison and Singh, 2003

» Wall of Science

• “We spend $25,000 for pills, procedures, andbedpans for every one dollar on patientsafety.”

» Wachter & Shojania, 2004

» Internal Bleeding





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HWE’s

• This is being demanded by:• The Public

• Policy Makers

• Regulators

• Health Care Professionals

• Common Sense and Doing the RightThing

AACN’S HWE

• Common Threads

• Organizational responsibilities

• Individual responsibilities

• Support for & access to educationalprograms related to each

• Leadership/administration support

TRUE COLLABORATION

• Accountabilitydefined

• Decision makingauthority

• Resources fordispute resolution

• Embrace “culture” ofcollaboration

• Ethical lim its

• Respect each voice

• Personal integrity

• Skilledcommunication

• Competence of allteam members

• Nurse and MD equalpartners in care





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TRUE COLLABORATION

• Patient and family satisfaction, patientsafety and outcomes, professional staffsatisfaction, nurse retention and cost.

• All related to collaboration !!!

EFFECTIVE DECISIONMAKING

• Organizationalvalues clear

• Structures assurepatients and familiesare heard

• Sharedaccountability fordecision making

• Respect for right ofall

• Incorporate all keyperspectives

• Evaluate results ofdecisions

• Cammy: hard data

EFFECTIVE DECISIONMAKING

• Responsibility=Accountability

• Authority

• National programs such as AACNBeacon Award for Critical CareExcellence, Magnet Nursing ServicesRecognition Program and the BaldrigeNational Quality Program.





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APPROPRIATE STAFFING

• Staffing policiessolidly grounded

• Nurses participate inentire staffingprocess

• Staffing decisionsare evaluated

• Most Harmful

• Cammy: turn over

• Access to staffingdata

• Support servicesavailable to ensurenurses focus onnursing work

• Technologiesadopted that ⇑effectiveness ofnursing caredelivery

STAFFING

• Medication Error: Reporting Error inPatient Care

• Will not do the variance reporting???

• Why not????

• A way to track and tell the system of aproblem

STAFFING

• Evidence suggests that better patientoutcomes result when a higher proportion ofcare hours is provided by registered nurses.

– Needleman J, N Engl J Med 2002:346:1715-1720

• Further research supports a relationshipbetween specialty certification and clinicalnursing expertise





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MEANINGFULRECOGNITION

• Comprehensiveprogram in placefor all

• Process forknowing how toparticipate

• Bedside to boardtable

• Includes process todetermine thatrecognition ismeaningful

• Recognition systemis regularlyevaluated

• Everyone isresponsible

RECOGNITION

Tweeners

Positrons Negatrons

RECOGNITION

• Establishing a Work Culture

• Role Modeling

• Mentorship• Fun

• Three L Philosophy

• Love it: Learn to love it:

• Leave it





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AUTHENTIC LEADERSHIP• LEADERS:

• Understandrequirements/

• dynamics at point ofcare

• Generate visibleenthusiasm

• Role model

• Evaluate their impact &progress toward HWE

• ORGANIZATION:

• Assure leaders are wellpositioned andsupported

• Provide time, financialand human resources

• Include leader’s role inHWE into performanceappraisal

LEADERSHIP

• MENTORING

• MOVING THE STAFF FORWARD

• ROLE MODEL

“Our days begin to end theday we become silent about

things that matter.”

Martin Luther King, Jr.





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HWE

• Call to action from AACN• National focus that becomes Patient

Centered Care with the Nurse as the“owner” and “driver” of excellence.

ALL ABOUTPLAYING IN THE SAND BOX

TOGETHER

DAILY GOAL CHECKLIST

THIS is patient Safety





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TOP THREE PRIORITIES TOD/C PT

• Greatest pt safety risk from the Unit• Review med; can any be discontinued?

• Review tests, procedures, scheduledlabs, X-rays; can any be discontinued?

• Review catheters and tubes; can anybe discontinued?

• Adequate comfort/pain management?

TOP THREE

• Activity/PT/OT/Rehab consults?

• Sedation indicated? Can it be weaned?Changed to oral?

• Respiratory/Ventilator goals

• Neurological-ICP/psychological issuesand goals?

• Renal, fluid balance goals, electrolytereplacement-oral?

TOP THREE

GI/Nutritional goals

Liver/Pancreas

Hematology/Coagulation=blood productinfusion criteria

ID: cultures, drug levels-appropriateagents and doses?

Reviewed consultations: new?





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TOP THREE

• Surgical Plans

• Communication with referring MD

• Family communication/social issues/code status

• Discharge planning--write transfer orders?

• Implement care protocols? Ventilator-weaningorders, sedation-weaning orders, glucose control,DVT & PUD prophylaxis?

TOP THREE

• HOB at 30 degrees

• Research protocol candidate? Glucosecontrol, extubation, bronchiolitis, etc.

GOALS

• Every Nurse, rounding MD, RespiratoryTherapist, PT, and all team members

should have same goals for patient andfamily

• Use Goal Checklist!!!!!

• Keep on Track for patient safety andHWE





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SAVE 100,000 LIVES

THE CAMPAIGN

HOW IT WORKS

HOW TO START

100,000 Lives Campaign Objectives(December 2004 – June 2006)

• Save 100,000 lives

• Enroll more than 2,000 hospitals in theinitiative

• Build a reusable national infrastructurefor change

• Raise the profile of the problem(variability in the quality of Americanhealth care) - and our proactive response

100,000 Lives

• Is an initiative to engage US hospitals in acommitment to implement changes in careproven to improve patient care and preventavoidable deaths. End date is June 2006.

• IOM est 98,000 pts die secondary to medicalerrors

• CDC est 2 million pts have Hospital acquiredinfections.





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Delivery of Evidenced-BasedCare

• Deployment of Rapid Response Team• Prevention of Adverse Drug Events

• Prevention of Central Line Infections

• Prevention of Surgical Site Infections

• Prevention of Ventilator-AssociatedPneumonia (VAP)

• Comprehensive Care of AMI

SAVE 100,000 LIVES

• HOB elevated! HOB elevated!

• No Nasal Tubes

• Sterile Technique

• Appropriate Sedation

• Glucose < 110 mg/dl

• Oral Care: Chlorhexidine

SAVE 100,000 LIVES

• Assessment of ability to extubate: venttraining protocols

• PUD prophylaxis• DVT prophylaxis

• HOB elevation > 30 degrees





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STRATEGIES

• Conventional Infection Control• Strategies Related to GI Tract

• Strategies Related to Patient Placement

• Strategies Related to Artificial Airways

• Conventional DVT Prophylaxis

Bundles• What is a "bundle"?

• A "bundle" is a group of interventions related toa disease process that, when executed together,result in better outcomes than whenimplemented individually.

• Examples of bundles include:

• * Ventilator Bundle

• * Central Line Bundle

• * Severe Sepsis Bundles

• * Ventilator Bundle

• * Central Line Bundle

• * Rapid Response Teams• * Multidisciplinary Rounds

• * Daily Goals Assessment

• * Intensivist Model

• * Effective Glucose Control





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BUNDLES

• Development of Bundles of CareVentilator Bundles

Sepsis Bundles

DVT Prophylaxis

PUD Prophylaxis

Central Line Bundles

Bathing/Mouth Care/Turning Bundles

An Introduction to the5 Million Lives Campaign

December 12, 2006

100,000 Lives Campaign Objectives(December 2004 – June 2006)

• Save 100,000 lives

• Enroll more than 2,000 hospitals in the

initiative• Build a reusable national infrastructurefor change

• Raise the profile of the problem(variability in the quality of Americanhealth care) - and our proactive response





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The Next Campaign

WE’RE GOING AFTER HARM…

Our Definition of Medical Harm

Unintended physical injury resulting from orcontributed to by medical care (including theabsence of indicated medical treatment), thatrequires additional monitoring, treatment orhospitalization, or that results in death.

Such injury is considered harm whether or not it isconsidered preventable, whether or not itresulted from a medical error, and whether ornot it occurred within a hospital.

For more information, please reference detailed FAQs at www.ihi.org/campaign.

The Next Campaign


but what do we mean by “harm”?





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The Next Campaign


but how much harm will we

reduce?

Logic Chain: Step 1

How Many Admissions perYear?

37 Mill ion Admissions

Source: The AHA National Hospital Survey for 2005

Logic Chain: Step 2

40 to 50 Patient Injuries per 100

Hospital Admissions

Source: IHI “Global Trigger Tool” Guiding Record Reviews

How Often Are Patients

Injured by Care?





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Logic Chain: Step 3

37 Million Admissions

X

40 Injuries per 100 Admissions

=

15 Milli on Injur ies per Year

How Many Injuries in the US?

The 5 Mill ion LivesCampaign

We are asking hospitals participating in theCampaign to prevent five million incidents ofmedical harm over the next two years.

Given the performance IHI has observed inhighly successful hospitals, and given all thatthe industry is investing in improving thequality of care nationally, we believe we can –and must – find a way to achieve such resultsin this period.

The 5 Mill ion LivesCampaign

• Campaign Objectives:

– Avoid five million incidents of harm over the next 24 months;

– Enroll more than 4,000 hospitals and their communities in

this work; – Strengthen the Campaign’s national infrastructure for

change and transform it into a national asset;

– Raise the profile of the problem – and hospitals’ proactiveresponse – with a larger, public audience.





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The six interventions from th e 100,000 Lives Campaign:

• Deploy Rapid Response Teams…at the first sign of patient decline

• Deliver Reliable, Evidence-Based Care for Acute MyocardialInfarction…to prevent deaths from heart attack

• Prevent Adverse Drug Events (ADEs)…by implementingmedication reconciliation

• Prevent Central Lin e Infections…by implementing a series ofinterdependent, scientifically grounded steps

• Prevent Surgi cal Site Infections…by reliably delivering the correctperioperative antibiotics at the proper time

• Prevent Ventilator-Associated Pneumonia…by implementing aseries of interdependent, scientifically grounded steps

The Platform• Prevent Pressure Ulcers... by reliably using science-based

guidelines for their prevention• Reduce Methicillin -Resistant Staphylococcus aureus (MRSA)

Infection…by reliably implementing scientifically proven infectioncontrol practices

• Prevent Harm from High-Alert Medications... starting with a focuson anticoagulants, sedatives, narcotics, and insulin

• Reduce Surgical Complications... by reliably implementing all ofthe changes in care recommended by the Surgical CareImprovement Project (SCIP)

• Deliver Reliable, Evidence-Based Care for Congestive HeartFailure…to reduce readmissions

• Get Boards on Board….Defining and spreading the best-knownleveraged processes for hospital Boards of Directors, so that theycan become far more effective in accelerating organizationalprogress toward safe care

www.ihi.org/campaign





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Introduction to Critical Care Nursing Module Sample Test Questions

1. What is the best level of evidence available for practice according to CDC?A. Level 3

B. Level 1a

C.

Level 2aD. Level 1b

2. Evidence-Based practice includes the art of medicine and the science of medicine.

A. TrueB. False

3. The Synergy model advocated that:A. The patient and family are the center of the universe

B. The health care team is the center of the universe

C. The administration is the center of the universe

D.

Government control should be the focus of health care policy

4. SCCM has tips to improve care in the critical care unit, this includes:

A. Nursing that is certifiedB. Standardizing practice

C. Improved physical environment

D. All the above

5. List four of the 10 effective habits that improve critical thinking skills:

A. Confidence, creativity, flexibility, open-mindednessB. Confidence, inflexibility, rigidness, discriminatory thinking

C. Confidence, creativity, discriminatory thinking, stubbornness

D.

Confidence, rigid thinking, unforgiving behavior, one-minded

6. Healthy work environment has an emphasis on patient outcomes, cost-effectiveness,

and consumer satisfaction.

A. TrueB. False

7. AACN’s Healthy Work Environment includes the following standards: skilledcommunication, true collaboration, effective decision-making, appropriate staffing,

meaningful recognition, and authentic leadership.

A. TrueB.

False

8. Communications problems do not represent the most common cause of sentinel

events.A. True

B. False





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9. The focus of AACN’s Healthy Work Environment includes a:A. Patient and family centered plan of care

B. Reduction of cost plan of care

C.

Communication care planD. All the above

10. Save 100,000 Lives was a campaign initiated by the Institute of Health Improvement

(IHI) for the development of a profile to improve patient care and prevent avoidabledeaths.

A. True

B. False

11. The resultant strategies developed from the profiles from the IHI Save 100,000 have

now been instituted nation wide and include the use of “bundles of care.”

A.

TrueB.

False

12. One of the most developed “bundles” in the Save 100,000 Lives was the:A. VAP Bundle

B. Communication Bundle

C. Sepsis BundleD. UTI Bundle

13. Other aspects of the Save 100,000 Lives Campaign provided information on manareas of patient care, including:

A. No nasal tubes

B.

Appropriate sedationC. Glucose control

D. All of the above

14. The definition of “bundle” includes a group of interventions related to a disease process, that, when executed together, result in better outcomes than when

implemented individually.

A. TrueB. False

15. In the platform for the six interventions for Save 100,000 Lives, the deployment of arapid response team:

A. Has shown to improve patient outcomes

B. Has shown to improve nurse/physician communication

C. Has shown to improve bedside assessmentsD. All the above





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16. The presence of a surgical site infection depends primarily on:A. Reliably delivering the correct perioperative antibiotic at the proper time

B. Continuing antibiotic therapy for one week post operatively

C.

Admitting the patient to the hospital two days before the surgery dateD. Use of betadine as a preoperative wash

17. The next national initiative by the IHI is still underway and is know as “Do No

Harm”. The goal of this campaign is to reduce the number of errors that result in patient injury.

A. True

B. False

18. How often are patients injured during their hospital stay?

A. 5 per 100 admissions

B.

10 per 100 admissionsC.

20 per 100 admissions

D. 40-50 per 100 admissions

19. The goal of the “Do No Harm” campaign is to reduce patient injury that results in

death by 5 million lives.

A. TrueB. False

20. In the Do NO Harm Initiative, prevention form harm from high alert medicationsincluded:

A. Anticoagulants

B.

Narcotics and sedativesC. Insulin

D. All the above





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Answers:

1.

B2. A

3. A

4. D

5. A6. A

7. A

8. B9. D

10. A

11. A

12.

A13.

D

14. A

15. D16. A

17. A

18. D19. A

20. D



Documents

Intro Critical Care Nursing Ex Med Ed