- Email: [email protected]
Delivering Resuscitation Medications to Pediatric Patients
PEDIATRIC UPDATE
DELIVERING RESUSCITATION MEDICATIONS TO PEDIATRIC PATIENTS Author: Joyce Foresman-Capuzzi, MSN, RN, CNS, CEN, CPN, CTRN, CCRN, CPEN, SANE-A, EMT-P, Prospect Park, PA Section Editors: Donna Ojanen Thomas, MSN, RN, Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, SANE-A, EMT-P, and Michelle Tracy, MA, RN, CEN, CPN
Earn Up to 8.5 CE Hours. See page 208. he emergency department is a stressful and highrisk area of the hospital at any time but particularly when ED staff are caring for an acutely ill child. ED nurses are dedicated, hard working, and highly skilled, but errors continue to occur despite the availability of specialized courses such as Pediatric Advanced Life Support and the ENA Emergency Nurse Pediatric Course. It is estimated that 1 in 4 patients seen in the emergency department is a pediatric patient1 and that medication errors occur in 10% of patients seen in a pediatric emergency department.2 Some reasons cited for these medication errors include the unique physiology of the child; the fact that drug doses are based on the child’s weight in kilograms, which means that an accurate weight must be obtained; and the requirement that a drug calculation be done, often in micro-calculations, for a majority of drug concentrations that are appropriate for adults rather than children. In addition, as reported by the Committee on Pediatric Emergency Medicine,3 “…when performing resuscitation tasks in children, opportunities for error are magnified …and each must be determined or calculated in a high-risk environment by using high-level cognitive skills.” Although color-coded resuscitation tapes simplify the task of choosing equipment and administering drugs on the basis of a child’s length, limitations still exist. The Committee on Pediatric Emergency Medicine 3 also reports, “Medication doses are listed on the tape in milligrams, yet nurses must draw up medications by volume. Although this tape provides precalculated medication doses, it does not provide the nurse with a precalculated volume (milliliters) of medication to administer. There is
T
Joyce Foresman-Capuzzi is Clinical Nurse Educator, Lankenau Medical Center, Wynnewood, PA. For correspondence, write: Joyce Foresman-Capuzzi, MSN, RN, Lankeanu Medical Center, 100 Lancaster Ave, Emergency Department, Wynnewood, PA 19096; E-mail: [email protected]. J Emerg Nurs 2011;37:194-9. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.12.009
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currently no clinical tool universally available to ED nurses that provide them with this critical information, and a recent study of a simulated pediatric emergency event suggests that errors may occur at this point in the process of emergent medication administration.” Although the variety of courses designed to help provide pediatric education for ED nurses often promote a comfort level in caring for critically ill children, a discrepancy can remain between the didactic knowledge gained and the ability to carry out the necessary skills confidently and competently. It is best to have pediatric preparations for drugs when they are available or a pharmacist to assist in the emergency department, but many facilities do not have this luxury. However, some practical tips and tricks can help ED nurses make the transition from head to hands and may be helpful in preparing for emergency situations. When caring for a child who is in cardiac arrest, epinephrine is often used. With the preferred delivery method being intravenous or intraosseous, the current 2010 American Heart Association guidelines instruct the rescuer to administer the dose as 0.01 mg/kg (0.1mL/kg) of a 1:10,000 concentration.4 The standard pre-filled epinephrine syringe in this concentration is 1 mg/10 mL (0.1 mg/ mL). Given the complex nature of the calculations necessary to administer and document the correct dosage, a simplified way to do the calculation and safely administer this important drug is needed. Currents, a publication of the American Health Association, suggests the following easy formula: “Remember the phrase PEDS = SD, which is the acronym for Pediatric Epinephrine Dosing Story = Slide Decimal. Step 1: Starting with the patient’s weight in kilograms, slide the decimal over one point to the left to determine the VOLUME (mL) of epinephrine to draw up. Step 2: Slide the decimal one more point over to the left to determine the AMOUNT (mg) of epinephrine to document on the code sheet.”5 With that simple formula in mind, practice is important. If a child weighs 9 kg, the volume of epinephrine administered is 0.9 mL and the number of mg to document is 0.09 mg. If the child weighs 18 kg, the volume of epinephrine to administer
VOLUME 37 • ISSUE 2 March 2011
Foresman-Capuzzi/PEDIATRIC UPDATE
is 1.8 mL, and documentation is 0.18 mg. The child who weighs 35 kg will receive 3.5 mL of epinephrine, and 0.35 mg is documented. Considering the way the epinephrine is delivered in the pre-filled syringe, and knowing that there are 1-mL markings on the glass, you could perhaps be able to give the 3.4 mL that you need to administer, but it would not be safe to do it in that manner. Giving small amounts of medication directly from the pre-filled syringe and not inadvertently giving too much medication or, without thinking, administering the entire syringe, as would be common practice in an adult, is too great a danger. As a result, you should not consider using this common adult method. Let’s consider a 10-lb baby. Because children should always be weighed in kilograms and all pediatric medications are weight based, conversion is 4.5 kg. How much epinephrine do you want to give? The child now needs 0.4 mL of epinephrine, and 0.04 mg should be documented on the code sheet. How are you going to safely deliver this small of a dose with the way the markings are provided on the pre-filled syringe? It cannot be done! In fact, an epinephrine dose of 1 mL or less is going to be used for any child up to 10.5 kg (23 lb). Keep in mind that many of the resuscitation medications are the same ones used for adult resuscitation. Some differences in concentration exist, such as D25 or sodium bicarbonate 8.4%, but they are few. What options exist to administer the small doses of the medications needed for the pediatric patient from the large pre-filled syringes? Even though you have just learned an easy way to administer epinephrine, that formula does not apply to all medications a child may need. First, you must perform the appropriate drug calculation to determine how much of a particular drug you need to administer. You should always verify your calculations with another nurse. Once that step is done, 2 methods can be used to obtain the correct amount of the medications. The one you choose is based on personal preference. The nurse preparing the medications should focus on this task and not be involved in other responsibilities during the resuscitation to ensure accuracy. If drugs are prepared before they are needed, they must be labeled with the medication name, dose, and strength, and thus preprinted syringe labels should be available. Step-by-step instructions are provided for the 2 methods of preparing emergency pediatric medication for administration. Choose the one that is right for you and use it, regardless of what medication you need to administer! By practicing now how to precisely and safely prepare a variety of medications for administration
March 2011
VOLUME 37 • ISSUE 2
FIGURE 1 A pre-filled syringe. This figure is available in color and as full-page document at www.jenonline.org.
to a critically ill child, you can be prepared and confident for one of the most stressful situations that ED nurses encounter.
Method 1
1. Get a prefilled syringe out of the box (Figure 1). 2. Assemble an 18-gauge needle (blunt it for safety) and a dose-appropriate syringe, in this case a TB syringe (without an attached needle) (Figure 2). Attach a needle onto the syringe. Use of a TB syringe will allow for precise doses of small amounts of medication for the pediatric patient. Use a 3- or 5-mL syringe for a larger child requiring largerdoses. 3. Open the side of the syringe pre-filled with medication (Figure 3). 4. Carefully insert the needle into the stopper of the prefilled medication syringe and withdraw the amount of needed medication into the attached syringe (Figure 4). Carefully remove the needle (if using a needleless system) from the syringe (in this case a TB syringe) and administer the medication intravenously or intraosseously to the patient (the endotracheal route not recommended). Repeat the process as needed. (Looking back at our example of the 10-lb baby, you can see how easily and precisely in this scenario we can administer the 0.4 mL of epinephrine needed.)
WWW.JENONLINE.ORG
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FIGURE 4 FIGURE 2 An 18-gauge needle and a TB syringe (without an attached needle). This figure is available in color and as full-page document at www.jenonline.org.
A needle is carefully inserted into the stopper of the pre-filled medication syringe and the amount of needed medication is withdrawn into the attached syringe. This figure is available in color and as full-page document at www. jenonline.org.
FIGURE 3 The side of the syringe that is pre-filled with medication is opened. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 5
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A pre-filled syringe. This figure is available in color and as full-page document at www.jenonline.org.
VOLUME 37 • ISSUE 2 March 2011
Foresman-Capuzzi/PEDIATRIC UPDATE
FIGURE 8 The leur lock end of the pre-filled syringe is attached to the stopcock. This figure is available in color and as full-page document at www.jenonline.org. FIGURE 6 A 3-way stopcock. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 9 A view of the assembly at this point. This figure is available in color and as fullpage document at www.jenonline.org.
Method 2
FIGURE 7 A cap from the stopcock is removed and discarded. This figure is available in color and as full-page document at www.jenonline.org.
March 2011
VOLUME 37 • ISSUE 2
1. Gather and then assemble a pre-filled syringe (Figure 5). 2. Obtain a 3-way stopcock (Figure 6). (If this is not something you have used much in the past, keep it in mind; I always carry one in my back pocket!) 3. Remove one of the caps from the stopcock and discard it (Figure 7).
WWW.JENONLINE.ORG
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PEDIATRIC UPDATE/Foresman-Capuzzi
FIGURE 10 The second cap of the stopcock is removed. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 12 A TB syringe is attached to the open end of the stopcock that was just flushed. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 11 The pre-filled syringe is flushed through just until medication appears in the open end of the stopcock. This figure is available in color and as full-page document at www.jenonline.org.
4. Attach the leur lock end of the pre-filled syringe to the stopcock (you just removed that cap) (Figure 8). 5. Figure 9 shows what your assembly looks like at this point. 6. Remove the second cap of the stopcock (Figure 10). 7. Your stopcock “dial” is “off” to the white end of stopcock. Flush the pre-filled syringe through until you just
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FIGURE 13 Medication is withdrawn from the pre-filled syringe just by pulling back on the TB syringe. This figure is available in color and as full-page document at www.jenonline.org.
VOLUME 37 • ISSUE 2 March 2011
Foresman-Capuzzi/PEDIATRIC UPDATE
back on TB syringe (Figure 13). There is no need to “push” the pre-filled syringe to fill the TB syringe. Detach the syringe from the stopcock and administer the medication to the patient. This process can be repeated as necessary. 10. You can see that by attaching a 3-mL syringe, you could safely and accurately administer medication to a heavier child (Figure 14); a 5-mL syringe can be used for an even larger child.
REFERENCES 1. Nadzam D, Westergaard F. Pediatric safety in the emergency department. J Nurs Care Quality. 2008;23:189-94. 2. Kozar E. Variables associated with medication errors in pediatric emergency medicine. Pediatrics. 2002;110:737-42. 3. Committee on Pediatric Emergency Medicine. Patient safety in the pediatric emergency care setting. Pediatrics. 2007;120:1367-75. 4. American Heart Association. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010. 5. American Heart Association. PEDS = SD. Currents. 2008;19(3):4.
FIGURE 14 A 3-mL syringe. This figure is available in color and as full-page document at www.jenonline.org.
see medication appear in open end of the stopcock (Figure 11). 8. Attach your syringe, in this case a TB syringe, to the open end of stopcock you just flushed (Figure 12). 9. Medication now can be easily withdrawn from the pre-filled syringe (as if it were a vial) just by pulling
March 2011
VOLUME 37 • ISSUE 2
Submissions to this column are encouraged and may be sent to Donna Ojanen Thomas, MSN, RN [email protected] or Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, SANE-A, EMT-P [email protected] or Michelle Tracy, MA, RN, CEN, CPN [email protected]
WWW.JENONLINE.ORG
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DELIVERING RESUSCITATION MEDICATIONS TO PEDIATRIC PATIENTS Author: Joyce Foresman-Capuzzi, MSN, RN, CNS, CEN, CPN, CTRN, CCRN, CPEN, SANE-A, EMT-P, Prospect Park, PA Section Editors: Donna Ojanen Thomas, MSN, RN, Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, SANE-A, EMT-P, and Michelle Tracy, MA, RN, CEN, CPN
Earn Up to 8.5 CE Hours. See page 208. he emergency department is a stressful and highrisk area of the hospital at any time but particularly when ED staff are caring for an acutely ill child. ED nurses are dedicated, hard working, and highly skilled, but errors continue to occur despite the availability of specialized courses such as Pediatric Advanced Life Support and the ENA Emergency Nurse Pediatric Course. It is estimated that 1 in 4 patients seen in the emergency department is a pediatric patient1 and that medication errors occur in 10% of patients seen in a pediatric emergency department.2 Some reasons cited for these medication errors include the unique physiology of the child; the fact that drug doses are based on the child’s weight in kilograms, which means that an accurate weight must be obtained; and the requirement that a drug calculation be done, often in micro-calculations, for a majority of drug concentrations that are appropriate for adults rather than children. In addition, as reported by the Committee on Pediatric Emergency Medicine,3 “…when performing resuscitation tasks in children, opportunities for error are magnified …and each must be determined or calculated in a high-risk environment by using high-level cognitive skills.” Although color-coded resuscitation tapes simplify the task of choosing equipment and administering drugs on the basis of a child’s length, limitations still exist. The Committee on Pediatric Emergency Medicine 3 also reports, “Medication doses are listed on the tape in milligrams, yet nurses must draw up medications by volume. Although this tape provides precalculated medication doses, it does not provide the nurse with a precalculated volume (milliliters) of medication to administer. There is
T
Joyce Foresman-Capuzzi is Clinical Nurse Educator, Lankenau Medical Center, Wynnewood, PA. For correspondence, write: Joyce Foresman-Capuzzi, MSN, RN, Lankeanu Medical Center, 100 Lancaster Ave, Emergency Department, Wynnewood, PA 19096; E-mail: [email protected]. J Emerg Nurs 2011;37:194-9. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.12.009
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JOURNAL OF EMERGENCY NURSING
currently no clinical tool universally available to ED nurses that provide them with this critical information, and a recent study of a simulated pediatric emergency event suggests that errors may occur at this point in the process of emergent medication administration.” Although the variety of courses designed to help provide pediatric education for ED nurses often promote a comfort level in caring for critically ill children, a discrepancy can remain between the didactic knowledge gained and the ability to carry out the necessary skills confidently and competently. It is best to have pediatric preparations for drugs when they are available or a pharmacist to assist in the emergency department, but many facilities do not have this luxury. However, some practical tips and tricks can help ED nurses make the transition from head to hands and may be helpful in preparing for emergency situations. When caring for a child who is in cardiac arrest, epinephrine is often used. With the preferred delivery method being intravenous or intraosseous, the current 2010 American Heart Association guidelines instruct the rescuer to administer the dose as 0.01 mg/kg (0.1mL/kg) of a 1:10,000 concentration.4 The standard pre-filled epinephrine syringe in this concentration is 1 mg/10 mL (0.1 mg/ mL). Given the complex nature of the calculations necessary to administer and document the correct dosage, a simplified way to do the calculation and safely administer this important drug is needed. Currents, a publication of the American Health Association, suggests the following easy formula: “Remember the phrase PEDS = SD, which is the acronym for Pediatric Epinephrine Dosing Story = Slide Decimal. Step 1: Starting with the patient’s weight in kilograms, slide the decimal over one point to the left to determine the VOLUME (mL) of epinephrine to draw up. Step 2: Slide the decimal one more point over to the left to determine the AMOUNT (mg) of epinephrine to document on the code sheet.”5 With that simple formula in mind, practice is important. If a child weighs 9 kg, the volume of epinephrine administered is 0.9 mL and the number of mg to document is 0.09 mg. If the child weighs 18 kg, the volume of epinephrine to administer
VOLUME 37 • ISSUE 2 March 2011
Foresman-Capuzzi/PEDIATRIC UPDATE
is 1.8 mL, and documentation is 0.18 mg. The child who weighs 35 kg will receive 3.5 mL of epinephrine, and 0.35 mg is documented. Considering the way the epinephrine is delivered in the pre-filled syringe, and knowing that there are 1-mL markings on the glass, you could perhaps be able to give the 3.4 mL that you need to administer, but it would not be safe to do it in that manner. Giving small amounts of medication directly from the pre-filled syringe and not inadvertently giving too much medication or, without thinking, administering the entire syringe, as would be common practice in an adult, is too great a danger. As a result, you should not consider using this common adult method. Let’s consider a 10-lb baby. Because children should always be weighed in kilograms and all pediatric medications are weight based, conversion is 4.5 kg. How much epinephrine do you want to give? The child now needs 0.4 mL of epinephrine, and 0.04 mg should be documented on the code sheet. How are you going to safely deliver this small of a dose with the way the markings are provided on the pre-filled syringe? It cannot be done! In fact, an epinephrine dose of 1 mL or less is going to be used for any child up to 10.5 kg (23 lb). Keep in mind that many of the resuscitation medications are the same ones used for adult resuscitation. Some differences in concentration exist, such as D25 or sodium bicarbonate 8.4%, but they are few. What options exist to administer the small doses of the medications needed for the pediatric patient from the large pre-filled syringes? Even though you have just learned an easy way to administer epinephrine, that formula does not apply to all medications a child may need. First, you must perform the appropriate drug calculation to determine how much of a particular drug you need to administer. You should always verify your calculations with another nurse. Once that step is done, 2 methods can be used to obtain the correct amount of the medications. The one you choose is based on personal preference. The nurse preparing the medications should focus on this task and not be involved in other responsibilities during the resuscitation to ensure accuracy. If drugs are prepared before they are needed, they must be labeled with the medication name, dose, and strength, and thus preprinted syringe labels should be available. Step-by-step instructions are provided for the 2 methods of preparing emergency pediatric medication for administration. Choose the one that is right for you and use it, regardless of what medication you need to administer! By practicing now how to precisely and safely prepare a variety of medications for administration
March 2011
VOLUME 37 • ISSUE 2
FIGURE 1 A pre-filled syringe. This figure is available in color and as full-page document at www.jenonline.org.
to a critically ill child, you can be prepared and confident for one of the most stressful situations that ED nurses encounter.
Method 1
1. Get a prefilled syringe out of the box (Figure 1). 2. Assemble an 18-gauge needle (blunt it for safety) and a dose-appropriate syringe, in this case a TB syringe (without an attached needle) (Figure 2). Attach a needle onto the syringe. Use of a TB syringe will allow for precise doses of small amounts of medication for the pediatric patient. Use a 3- or 5-mL syringe for a larger child requiring largerdoses. 3. Open the side of the syringe pre-filled with medication (Figure 3). 4. Carefully insert the needle into the stopper of the prefilled medication syringe and withdraw the amount of needed medication into the attached syringe (Figure 4). Carefully remove the needle (if using a needleless system) from the syringe (in this case a TB syringe) and administer the medication intravenously or intraosseously to the patient (the endotracheal route not recommended). Repeat the process as needed. (Looking back at our example of the 10-lb baby, you can see how easily and precisely in this scenario we can administer the 0.4 mL of epinephrine needed.)
WWW.JENONLINE.ORG
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PEDIATRIC UPDATE/Foresman-Capuzzi
FIGURE 4 FIGURE 2 An 18-gauge needle and a TB syringe (without an attached needle). This figure is available in color and as full-page document at www.jenonline.org.
A needle is carefully inserted into the stopper of the pre-filled medication syringe and the amount of needed medication is withdrawn into the attached syringe. This figure is available in color and as full-page document at www. jenonline.org.
FIGURE 3 The side of the syringe that is pre-filled with medication is opened. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 5
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JOURNAL OF EMERGENCY NURSING
A pre-filled syringe. This figure is available in color and as full-page document at www.jenonline.org.
VOLUME 37 • ISSUE 2 March 2011
Foresman-Capuzzi/PEDIATRIC UPDATE
FIGURE 8 The leur lock end of the pre-filled syringe is attached to the stopcock. This figure is available in color and as full-page document at www.jenonline.org. FIGURE 6 A 3-way stopcock. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 9 A view of the assembly at this point. This figure is available in color and as fullpage document at www.jenonline.org.
Method 2
FIGURE 7 A cap from the stopcock is removed and discarded. This figure is available in color and as full-page document at www.jenonline.org.
March 2011
VOLUME 37 • ISSUE 2
1. Gather and then assemble a pre-filled syringe (Figure 5). 2. Obtain a 3-way stopcock (Figure 6). (If this is not something you have used much in the past, keep it in mind; I always carry one in my back pocket!) 3. Remove one of the caps from the stopcock and discard it (Figure 7).
WWW.JENONLINE.ORG
197
PEDIATRIC UPDATE/Foresman-Capuzzi
FIGURE 10 The second cap of the stopcock is removed. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 12 A TB syringe is attached to the open end of the stopcock that was just flushed. This figure is available in color and as full-page document at www.jenonline.org.
FIGURE 11 The pre-filled syringe is flushed through just until medication appears in the open end of the stopcock. This figure is available in color and as full-page document at www.jenonline.org.
4. Attach the leur lock end of the pre-filled syringe to the stopcock (you just removed that cap) (Figure 8). 5. Figure 9 shows what your assembly looks like at this point. 6. Remove the second cap of the stopcock (Figure 10). 7. Your stopcock “dial” is “off” to the white end of stopcock. Flush the pre-filled syringe through until you just
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JOURNAL OF EMERGENCY NURSING
FIGURE 13 Medication is withdrawn from the pre-filled syringe just by pulling back on the TB syringe. This figure is available in color and as full-page document at www.jenonline.org.
VOLUME 37 • ISSUE 2 March 2011
Foresman-Capuzzi/PEDIATRIC UPDATE
back on TB syringe (Figure 13). There is no need to “push” the pre-filled syringe to fill the TB syringe. Detach the syringe from the stopcock and administer the medication to the patient. This process can be repeated as necessary. 10. You can see that by attaching a 3-mL syringe, you could safely and accurately administer medication to a heavier child (Figure 14); a 5-mL syringe can be used for an even larger child.
REFERENCES 1. Nadzam D, Westergaard F. Pediatric safety in the emergency department. J Nurs Care Quality. 2008;23:189-94. 2. Kozar E. Variables associated with medication errors in pediatric emergency medicine. Pediatrics. 2002;110:737-42. 3. Committee on Pediatric Emergency Medicine. Patient safety in the pediatric emergency care setting. Pediatrics. 2007;120:1367-75. 4. American Heart Association. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010. 5. American Heart Association. PEDS = SD. Currents. 2008;19(3):4.
FIGURE 14 A 3-mL syringe. This figure is available in color and as full-page document at www.jenonline.org.
see medication appear in open end of the stopcock (Figure 11). 8. Attach your syringe, in this case a TB syringe, to the open end of stopcock you just flushed (Figure 12). 9. Medication now can be easily withdrawn from the pre-filled syringe (as if it were a vial) just by pulling
March 2011
VOLUME 37 • ISSUE 2
Submissions to this column are encouraged and may be sent to Donna Ojanen Thomas, MSN, RN [email protected] or Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, SANE-A, EMT-P [email protected] or Michelle Tracy, MA, RN, CEN, CPN [email protected]
WWW.JENONLINE.ORG
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