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  • 1. 1 Southwest Tennessee Community College Associate Degree Nursing Program Spring 2012 Group I Adult Health Nursing I (NURS 1213-251) Class Date Topic Faculty I Jan 12 Orientation Cummings/Livisay Unit IV Diabetes Livisay II Jan 17 Unit IV Diabetes Livisay III Jan 19 Unit III Cardiovascular Cummings IV Jan 24 Unit I GU and Blood Cummings V Jan 26 Exam I (Diabetes, GU, and Cardiovascular) Cummings/Livisay Exam I Review 1030-1130 VI Jan 31 Unit II Respiratory Cummings/Livisay Cummings VII Feb 2 Unit II Respiratory Cummings Unit V Cancer Livisay VIII Feb 7 Unit V Cancer Livisay IX Feb 9 Exam II (Respiratory & Cancer) Cummings/Livisay Exam II Review 1030-1130 X Feb 14 Unit IV Hepatic/Pancreatic Cummings/Livisay Cummings XI Feb 16 Unit VI Gastrointestinal Livisay XII Feb 21 Unit VI Gastrointestinal Livisay (2 hour) XIII Feb 23 Exam III (Pancreatic, Hepatic & GI) 915- Cummings/Livisay 1015 XIV Feb 28 Exam III Review 1030-1130 HESI 910-1110 XV Mar 1 Final Exam (910-1110 a.m.) Cummings/Livisay
  • 2. 2 UNIT I: The Focus of This Unit Deals With The Nursing Care Of The Client With Genitourinary Problems, Blood And Blood Administration. LEARNING OUTCOMESA. Genitourinary 1. Explain the etiology, pathophysiology, clinical manifestations, treatment and nursing care of clients with the urinary disorders: Pyelonephritis Renal Calculi Benign Prostatic Hypertrophy 2. Discuss the changes with urinary function and the prostate gland as i relates to aging and the implications for nursing care. 3. Explain the nursing implications of drugs used in the treatment of clients with Pyelonephritis, renal calculi, and BPH. 4. Discuss nursing implications and client education related to caring for clients after prostatectomy. 5. Identify and discuss the medical and surgical treatment of prostate cancer. 6. Discuss the nursing implications on the psychosocial needs of the patient with GU disorders.B. Blood Administration 7. Identify different blood types. 8. Differentiate between blood and blood component therapy and their indication for use. Whole Blood Packed RBCS Plasma Platlets Blood Alternative Products, Packed Cells, Plasma Administration, Platelets, Factor Administration And Blood Alternative Administration.9. Identify complications/adverse reactions related to blood donation and blood transfusion.
  • 3. 310. Discuss the medical and nursing management of patients experiencing complications/adverse reactions to blood donation or transfusion.11. Identify disqualifying factors associated with blood donation.12. Identify misconceptions and religious beliefs regarding blood donation and transfusion. ACTIVITIES1. Review A&P GU system.2. Review the procedure, prep and client education for the following: BUN, glomerular filtration rate (GFR), , retrograde pyelography, renalangiogram/renal biopsy , cystometrography (CMG), voiding cystourethrography (VCUG)3. Prepare medication sheets or drug cards for the following medications: Trimethoprim-sulfamethoxazole (Bactrim), levofloxin(Levaquin),gentamicin sulfate (Garamycin) GU prostate meds: finasterade (Proscar), terazosin ( Hytrin), tamsulosin (Flomax),saw palmetto & GU irrigant:Glycine, B&O suppository4. Prepare medication sheets or drug cards for the following medications: acetaminophen (Tylenol), diphenhydramine (Benadryl), and deferoxamine(Desferol).5. Design a pamphlet/poster to promote wellness and prevent the health problems studied in this course.RESOURCESLemone - Medical Surgical Nursing Chapters: 26-27Delaune - Fundamentals of Nursing Standards and Practice:Lemone – Medical Surgical Nursing Chapter 11; pp. 244-248, 263& 1078Lehne – Pharmacology pp. 636, 824-827 & 840-842
  • 4. 4 UNIT II: The Focus Of This Unit Deals With The Nursing Care Of The Client With Respiratory Problems. LEARNING OUTCOMES1. Compare and contrast the etiological and pathological factors, the medical and surgical interventions, nutrition, medications and nursingresponsibilities for clients with the following respiratory dysfunctions: Pneumonia Chronic Obstructive Pulmonary Disease Tb Pulmonary Embolism Lung Cancer2. Explain therapeutic communication techniques to use when performing a nursing history of the adult client with a chronic stable respiratoryalteration.3. Describe nursing assessment and data collection of clients with problems of the respiratory system.4. Differentiate between normal, abnormal, and adventitious breath sounds.5. Discuss lifestyle and environmental factors that increase the client’s risk for developing respiratory problems.6. Discuss the use and benefit of the following respiratory treatments: Postural Drainage Breathing Exercises Inhalers (MDI) Coughing Suctioning (Tracheal And Oropharyngeal)7. Discuss signs and symptoms of oxygen deficit.8. Identify JCAHO’s National Health Safety Goals (7) in regard to pneumonia and nosocomial respiratory infections.9. Identify and discuss the significance of various abnormal respiratory patterns (Cheyne-stokes, Kussmaul and Biot’s breathing).10. Discuss nursing measures which promote normal respirations.11. Identify primary methods of oxygen administration, contraindications, safety measures and nursing implications.12. Explain the nursing implications of drugs used in the treatment of clients with respiratory problems: bronchodilators, expectorants, antitussiveand corticosteroids.13. Discuss how arterial blood gases and pulse oximetry are used to monitor respiratory function and identify common changes seen in clients withpulmonary dysfunction.
  • 5. 514. Identify differences in respiratory acidosis and alkalosis, as well as compensatory mechanism with the respiratory client.15. Discuss various types of artificial airways and the nursing responsibilities for: Tracheostomy Endotracheal Tube Oral Airway16. Discuss the nurse’s role in managing care according to prioritized client needs.17. Identify possible illness patterns that could indicate an unusual respiratory infectious disease outbreak. ACTIVITIES1. Review anatomical and physiological processes related to the respiratory system.2. Review the following respiratory diagnostic test: VQ Scan, ABG’s, PEAK EXPIRATORY FLOW Chest X-Ray, CT And MRI Of Lung.3. Prepare medication sheets or drug cards for RESCUE INHALERS: Albuterol (Proventil) Levalbuterol (Xopenex) LONG-ACTING INHALERS: Ipratropium (Combivent) Salmetrol (Advair,) Formoterol (Foradil) Heophylline (Bronkodyl) Guaifenesin (Robitussin, Mucinex) Benzonatate (Tessalon)
  • 6. 6 Glucocorticoids (Prednisone And Solumedrol), Fluticasone) (Tiotropium) (Spiriva) Terbutaline (Brethine) Ontelukast (Singulair) Levofloxin (Levaquin) Ceftriaxone (Rocephin Heparin Enoxaparin(Lovenox) And Warfarin (Coumadin), Ciprofloxacin4. Design a pamphlet/poster to promote wellness and prevent the health problems studied in this course.RESOURCESLemone – Medical Surgical Nursing Chapters: 34, 37 & pp.1143-1147Lehne – Pharmacology Chapters: 75-76
  • 7. 7 UNIT III: The Focus Of This Unit Deals With The Nursing Care Of The Client With Cardiovascular Problems LEARNING OUTCOMES1. Assess the client history and identify risk factors in clients experiencing cardiovascular problems.2. Identify common diagnostic tests related to cardiovascular functioning: cardiac catheterization, thallium treadmill, cardiac enzymes, prothrombintime (protime, PT), international normalizing ratio (INR), partial Thromboplastin time (PTT), electrocardiography (EKG), echocardiogram (ECHO),coronary angiography, transesophageal electrocardiography (TEE).3. Discuss how cardiovascular diseases and other pyschophysiological disorders are related. Hypertension4. Review and discuss the pathophysiology, etiology, incidence and prevention of uncomplicated hypertension.5. Discuss the differences between primary and secondary hypertension: pathophysiology, clinical signs and symptoms, medical treatment, nursingcare and client teaching.6. Review categories of pharmacological agents used to treat essential hypertension, e.g., diuretics, antihypertensive, vasodilators, etc.7. Identify and discuss reasons for non-compliance to antihypertensive therapy. Coronary Atherosclerosis8. Discuss the difference between arteriosclerosis and atherosclerosis, including pathophysiology, incidence, and prevention.9. Identify nursing responsibilities and teaching to be included for the client and family with coronary artery disease.10. Identify the etiology, pathophysiology clinical manifestations, medical treatments and nursing responsibilities for clients with angina pectoris.11. Discuss current pharmacological agents and nursing implications of drugs used in the treatment of clients with angina pectoris.12. Discuss how emotional stress leads to the development and worsening of angina pectoris.13. Discuss the nurse’s role in managing care according to prioritized client needs. ACTIVITIES1. Review anatomical and physiological processes related to cardiovascular perfusion.2. Prepare medications sheets or drug cards for each of the following: Furosemide (Lasix), Hydrochlorothiazide (HCTZ), Nitroglycerin (Nitro-Dur),
  • 8. 8 Isosorbide Dinitrate (Isordil), Propranolol (Inderal), Metoprolol (Lopressor), Nifedipine (Procardia), Diltiazem (Cardizem) , Sodium Nitroprusside (Nitropress, Nipride), Hydralazine HCL (Apresoline)3. Prepare medication sheets or drug cards for each of the following: Morphine, Streptokinase, Tissue Plasminogen Activator (t-PA)4. Design a pamphlet/poster to promote wellness and prevent the health problems studied in this course.RESOURCESLemone – Medical Surgical Nursing Chapters: 29-30 32; pp. 1018-1034Lehne – Pharmacology Chapters 43-46 & 49-51Lehne – Pharmacology Chapters 49- 51
  • 9. 9 UNIT IV: The focus of this unit deals with the nursing care of clients with Diabetes Mellitus, pancreatic and hepatic disorders. LEARNING OUTCOMES1. Identify the most common types of diabetes according to etiology, pathophysiology and clinical manifestations across the lifespan.2. Discuss teaching/learning strategies to be used in communicating the role of diet, exercise and weight control to the adult client with diabetesmellitus.3. Discuss the clinical manifestations of short and long term complications of DIABETES MELLITUS Hypoglycemia Hyperglycermia Hyperosmolar Hyperglycermia Nonketotic Syndrome (Hhs) Diabetic Ketoacidosis Microvascular Changes Diabetic Neuropathy Diabetic Retinopathy Diabetic Nephropathy4. Discuss current medical treatment and nursing implications for clients with diabetic retinopathy.5. Assess client knowledge of disease and discuss important information to be included in a teaching plan for client’s who self-administer insulin.6. Discuss current pharmacological agents and nursing implications of drugs used in the treatment of clients with Diabetes Mellitus.7. Identify factors that affect the client’s adherence to a medical regimen: developmental level, cultural, spiritual variations.8. Discuss the advantages and disadvantages of the insulin pump system and nursing implications.9. Identify and discuss community support groups for clients and their families who are diagnosed with diabetes.10. Identify and review diagnostic tests and nursing implications of blood glucose monitoring.11. Discuss appropriate nursing diagnoses diabetes with short-term complications.12. Discuss appropriate nursing diagnoses for diabetes with long-term complications.
  • 10. 1013. Identify community resources available to the student and staff to remain current on knowledge related to adult clients with diabetes.14. Discuss the nurse’s role in managing care according to prioritized client needs. Hepatic and Pancreatic Disorders15. Monitor diagnostic tests related to hepatic dysfunction.16. Identify the most common types of hepatitis according to etiology, pathophysiology and clinical manifestations across the lifespan.17. Discuss safety measures necessary to prevent the spread of hepatitis.18. Identify the current treatment for cirrhosis, hepatitis, and cancer of the liver to include dietary regimen, medications, alteration in ADLs and threats to basic needs.19. Identify and discuss nursing responsibilities and possible legal ethical dilemmas in cases of liver transplants.20. Identify community health resources available for referral to support the client with potentially life threatening liver diseases.21. Monitor diagnostic tests related to pancreatic dysfunction.22. Discuss the difference between acute and chronic pancreatitis in relation to pathophysiology, etiology, signs/symptoms, and treatment.23. Utilize the nursing process to identify the appropriate nursing care for the client wit pancreatic and/or hepatic dysfunction.24. Discuss teaching/learning strategies for the adult client with pancreatic and/or hepatic disorders using the appropriate communicationtechniques for age, culture, and educational level.25. Discuss emotional adaptive behaviors and socioeconomic implications for adult clients with pancreatic and/or hepatic disorders.26. Discuss the clinical manifestations and management of complications associated with pancreatic and hepatic disorders. ACTIVITIES1. Prepare medication sheets or drug cards on each of the following: Glyburide (Micronase) Glipizide (Glucotrol) Metformin (Glucophage) Rosiglitazone (Avandia) Lispro (Humulog) Humulin N Humulin R Glargine (Lantus) Novolin 70/30 Novolog 70/30
  • 11. 112. Address objectives as study questions.3. Prepare medication sheets or drug cards on the following medications: Immune Globulin Lamivudine (Epivir) Adefovir (Hepsera) Iinterferon Alfa -2a, 2b (Intron Peg Interferon Ribavirin (Rebetol Chronulac (Lactulose) Neomycin (Neo- Tabs) Aquamephyton Phytonadione (Vitamin K) Folic Acid Vsopressin (Pitressin) Aminocaproic Acid (Amicar) Pancrease Mt (Pancrelipase) Hepatic Herbal Preparations (Milk Thistle, Silymarin)5. Design a pamphlet/poster to promote wellness and prevent the health problems studied in this course.RESOURCESLemone – Medical Surgical Nursing Chapter: 20Lemone – pp. 539-547, 825, 849, 850t &1599-160Lehne – Pharmacology Chapter: 56Lemone – Medical Surgical Nursing Chapter 25Lehne – Pharmacology Chapter 92, pp. 1076-1080
  • 12. 12 UNIT V: This Unit Focuses Deals With The Nursing Care Of The Client With Cancer And Those Receiving Treatment LEARNING OUTCOMES1. Describe the growth patterns of neoplasms that are classified as: benign or malignant.2. Define the term cancer and discuss the psychological affects of having a diagnosis of cancer.3. Discuss the incidence of cancer in relation to gender, age, race and geography.4. Identify risk factors that increase the client’s risk of developing cancer.5. Discuss the nursing implications in the following cancer diagnostic procedures: Tumor Markers Cytologic Tests Mammogram6. Discuss medical treatment options and types of surgeries related to cancer and nursing implications: Radiation Gene Therapy Chemotherapy Biological Response Modifiers Bone Marrow Transplant Tumor Removal Stem Cell Transplant Reconstruction7. Identify the nurse’s role in caring for clients receiving external and internal radiation therapy.8. Discuss classifications of chemotherapeutic agents and nursing implications for the client receiving chemotherapy.9. Identify side effects to radiation and chemotherapy and the nursing implications for the client with cancer.10. Discuss the following oncologic emergencies and the nursing care required: Superior Vena Cava Syndrome Tumor Lysis Syndrome Hypercalcemia Syndrome Of Inappropriate Adh (Siadh) Pericardial Effusion Cardiac Tamponade
  • 13. 1311. Identify the nurse’s role in assisting clients with coping to the following effects of cancer. a) pain b) malnutrition c) infections d) skin breakdown12. Identify community resources available to clients and families with a diagnosis of cancer.13. Identify the nurse’s role in assisting clients and families with end-of-life issues (i.e., advance directives).14. Discuss the three most common cancers in both females and males.15. Identify specific medical therapy and surgical interventions for cancer (hormones, chemotherapy, radiation, etc.).16. Identify resources available to the student and the staff to remain current on knowledge related to the care of the adult client with cancer.17. Define the role of hospice care nurse in the care of the client with a diagnosis of cancer.18. Identify and discuss appropriate nursing diagnoses for cancer.19. Discuss the nurse’s role in managing care according to prioritized client needs. ACTIVITIESThe cancer unit is done via the cancer module “Oncology Nurse” in the computer labs. The units to be covered and objectives will be found in thecontent folder in PAWS.1. Review anatomy and physiology of the cell.2. Review the nursing implications for the following diagnostic procedures in regard to cancer: CAT Scan MRI Stool For Occult Blood Chest And Body X-Ray
  • 14. 143. Prepare medication sheets and drug cards for the following medications: Doxorubicin (Adriamycin) Tamoxifen (Nolvadex) Cyclophosphamide (Cytoxan) Cisplatin (Platinol) Vincristine (Oncovin) Methotrexate 5-Fluorouracil (5-F4. Review the signs of impending clinical death.5. Review Kubler-Ross’s stages of grieving6. Design a pamphlet/poster to promote wellness and prevent the health problems studied in this course.RESOURCESLemone – Medical Surgical Nursing Chapter: 14Lehne – Pharmacology Chapters: 100-102Lemone – Medical Surgical Nursing Chapter 5
  • 15. 15 UNIT VI: THIS UNIT FOCUSES ON THE NURSING RESPONSIBILITIES OF CLIENTS WITH GASTROINTESTINAL DISORDERS LEARNING OUTCOMES.1. Discuss signs and symptoms that are indicators of GI disorders.2. Discuss nursing responsibilities and client education for the following diagnostic tests: Barium Swallow Barium Enema Cytology Ultrasound Radionuclide Uptake Gastroscopy Colonoscopy Rectal Biopsy CT Scan Of Abdomen3. Discuss indications for administration of total parental nutrition (TPN) and nursing implications associated with TPN.4. Discuss the etiology, pathophysiology, clinical manifestations, medical and surgical treatment and nursing care for the following disorders: Gastroesophogeal Reflux (GERD) Hiatal And Inguinal Hernias Peptic Ulcer Disease (PUD) Duodenal And Gastric Ulcers Acute And Chronic Gastritis Appendicitis Peritonitis5. Discuss dietary recommendations for clients with GI disorders.
  • 16. 166. Discuss the action, side effects, and nursing responsibilities for gastrointestinal drugs; Antacids Anticholinergics H2 Receptor Antagonists Drugs Mucosal Barrier Fortifiers Prostaglandin Analogs Proton Pump Inhibitors7. Describe the following surgical procedures, the nursing interventions, and client education related to each: Gastric Resection Billroth I Billroth II8. Discuss appropriate therapeutic communication techniques interacting with clients with GI disorders.9. Discuss the following post-gastrostomy complications: Nutritional Deficiency Pernicious Anemia Osteomalacia10. Identify signs and symptoms, medical treatment and nursing care of clients with dumping syndrome.11. Discuss the etiology, pathophysiology, clinical manifestations, medical and surgical treatment and nursing care for the following bowel disorders: Irritable Bowel Syndrome Ulcerative Colitis Crohn’s Disease Diverticular Disease Intestinal Obstruction Volvulus12. Identify appropriate nursing diagnoses for addressing the client’s psychological and emotional adaptation to a fecal diversion.13. Discuss the nurse’s role in assisting the client with an ileostomy, colostomy, or cecostomy with adapting to self-care (irrigation, dressings, anddietary changes).
  • 17. 1714. Identify signs and symptoms of complications, pertinent assessment, and education of the client following intestinal surgery in regard to these conditions: Prolapse Of The Stoma Retraction Of The Stoma Ileostomy Dysfunction Fistula Herniation15. Identify community agencies available to assist the client with fecal diversion.16. Discuss nursing responsibilities and client education for the following diagnostic tests associated with disorders of the gallbladder: Urobilinogen Serum Bilirubin Alkaline Phosphatase (Alp) Endoscopic Retrograde Cholangiopancreatography (Ercp) Esophagogastroduodenoscopy (Egd)17. Discuss pre/post-operative care of the client having surgery of the gallbladder (i.e., laproscopic technique, positioning, t-tube care, pain, andassessment).18. Discuss specific complications that may occur following gallbladder and bile duct surgery and the medical management.19. Identify individuals that are at risk for colorectal cancer.20. Discuss the importance of age appropriate annual screenings for colorectal cancer.21. Identify specific medical, nursing and surgical interventions for colorectal cancer. ACTIVITIES1. Review anatomy and physiology of the gastrointestinal system.2. Review the mechanical and chemical processes of digestion.3. Review the nursing responsibilities and client education for stool studies.4. Prepare medication sheets or drug cards forthe following medications: Cimetidine (Tagamet), Famotidine (Pepcid), Lansoprazole (Prevacid), Pantoprazole (Protonix), Calcium Carbonate (Tums),
  • 18. 18 Magnersium Hydroxide (Maalox), Bismuth Subsalicylate (Pepto Bismol), Metrodinazole(Flagyl); Aminosalicylates-Sulfasalazine (Azulfidine), Mesalamine (Asacol), Prostaglandin Analog- Misoprostol (Cytotec); Sulcrafate (Carafate), Tegasarod (Zelnorm); Metoclopramide (Reglan), Promethazine(Phenergan), Ondansetron (Zofran).5. Design a pamphlet/poster to promote wellness and prevent the health problems studied in this course.RESOURCESLemone – Medical Surgical Nursing Chapters: 21-24Lehne – Pharmacology Chapters: 77-79
  • 19. 19 DATE TOPICS OBJECTIVES STUDENT ACTIVITIES Introduction to course UNIT I 1/12 Conception/Fetal development 1-3,5 Chap 3, 12 & 13Thursday Fetal Circulation 4 6 Physiological changes during pregnancy Signs of pregnancy 7 1/17 Common discomforts of pregnancy 8,9 Chapters 3, 4, 13, 15 & 26Tuesday Normal AP client; assessments/ vaccines 10,22 15 Fetal diagnostics Psychological responses to pregnancy 11 01/19 Nutritional needs of pregnant client; alt socioeconomic/cultural clients 12,14 Chapters 1, 2, 4,5, 13,14, 15 & 32Thursday Adaptations to pregnancy 13 Variations/barriers in prenatal care; Ethical issues 17,18,19 Violence against women 01/24 Pregnant client during a disaster; pre/post disaster assessments, type of disasters 20,21,23Tuesday Complications of early pregnancy Unit II 01/26 Concurrent disorders during pregnancy, Trauma 1,2,3Thursday Disorders of the placenta 4 Chapters 7, 27, 28, 29, 30, & 31 Hypertensive disorders 5 6 Infections during pregnancy/ STD’s 01/31 EXAM # 1-Units I & II UNIT IIITuesday Theories of labor; premonitory signs 1,2 Chapter 16 & 19 True vs. False lab 3 Stages of Labor 4, 11 Feto-pelvic relationships 5-10 02/02 Nursing care during labor; immediate care of the newborn 12,19,20Thursday 13,14,8 Chapters 16, 17,18, 19, & 33 Pain management during labor Care of the Cesarean section client Fetal Assessment; fetal distress 15-18 02/07 Complications of labor; obstetrical procedures 21,22 Chapters , 20, 21, 31, 33, & 34Tuesday Physiological changes during PP; mgmt nursing & pharmacological UNIT IV 1-3, 4-7 Postpartum complications
  • 20. 20 Psychological adaptations PP 9-10 02/09 Mental disorders during the PP period 10-13 Chapters 8,21, 22, & 32,Thursday Family w/child with special needs 14 15 PP hlth education/ community resource/care at home 16,17 Birth control methods EXAM 2 – Units III & IV 02/14 Newborn nutrition and feeding/lactation UNIT V Tuesday NB physiological adaptation 1-3, 18 Chapter 23, 24, & 25 4 Behavioral characteristics of NB 5 NB assessments- cardio/thermoregulation 6 Gestational age assessment Care of the NB with a circumcision 7 02/16 Complication of the NB of various gestational ages 8-10 Chapters 35, 36, 37, & 38Thursday Complication of the NB; acquired or 11 12 Congenital conditions Abortions; spontaneous vs. elective- ethical implications UNIT VI 02/21 Infertility; diagnosis/treatment 1,2 Chapters 6, 8, & 9 Tuesday Menopause; changes/treatment 3-11 Benign problems of the breast 02/23 Diagnostic procedures for cancer 12Thursday Breast/ovarian cancer- diagnosis 13-15 Chapters 6, 10 & 11 16,17,19,20 Treatments for breast cancer/nursing care 21 Nurse role’s in cancer care 18 Community resources 2/28 EXAM 3 - UNITS V & VI Tuesday HESI-6:15 02/29Wednesday FINAL EXAM
  • 21. 21 TOPICAL OUTLINEUnit THE NURSING PROCESS AS IT RELATES TO: I 1. Conception and development of the placenta, umbilical cord and fetal membranes with the function of each 2. Development of fetus during each trimester with fetal circulation emphasized 3. Physiological changes during labor and common discomforts associated with these changes 4. Assessment of the prenatal client with special attention to her medical and obstetrical history combined with a physical examination allowing risk factors to be identified 5. Nutritional requirement of the pregnant client throughout the pregnancy with special attention to the adolescent client and those client with various cultural backgrounds 6. Assessment of the fetus during the prenatal period is association with those complications that may occur as a result of the pregnancy or those that were predisposing 7. The pregnant client during a disaster or emergency and available care identified within the communityUnit THE NURSING PROCESS AS IT RELATES TO: II 1. Those conditions that may occur during early pregnancy and result in pregnancy loss. 2. Management of those preexisting conditions and their effects on the pregnancy 3. Hemorrhagic disorders during late pregnancy 4. Hypertensive conditions that may be either preexisting or actually a result of the pregnancy and the severity of the latter as it jeopardizes fetal safety 5. Those infectious processes that may cause fetal anomalies, loss of pregnancy, and/or preterm labor
  • 22. 22Unit THE NURSING PROCESS AS IT RELATES TO: III 1. The theories of labor and those premonitory signs of true labor with differentiation of false labor reviewed 2. Stages of labor with the physical and psychological reactions to the events during the stages 3. Fetopelvic relationships and their importance to labor, type of delivery, nursing care, and operative procedures that may be required for delivery 4. Analgesia and anesthesia available for the laboring client with client and fetal safety a priority 5. Fetal monitoring during labor and those interventions that may correct any baseline changes and/or no reassuring patterns 6. The immediate care of the newborn involving the APGAR assessment and medications given in the delivery room 7. Complications of the laboring process that may relate to the pelvis, passenger, and /or the passageway. 8. Preterm labor and premature rupture of membranes and the implications of each to fetal survival 9. The use of oxytoxic medications to induce labor in certain conditions and the potential complication of those medications for the client and the fetus 10.Those obstetrical procedures that are implemented to shorten Stage 2 of labor or as an alternative to a vaginal delivery as required by medical complication or the labor or delivery processUnit THE NURSING PROCESS AS IT RELATES TO: IV 1. The physiological alterations of the postpartum client that occur normally after vaginal or Cesarean delivery 2. Potential complications that may occur during the early or late postpartum period that may be life threatening 3. Areas of teaching that are required for the client after delivery to promote self care and care of the newborn 4. Nutritional needs of the new mother for her own wellbeing and recovery and those needs if she is breastfeeding 5. Adaptation of the new parents to the newborn with variations of the family unit including that of the adolescent in the absence of the father of the infant 6. Those psychological disorders that may result during this period that may or may not warrant intervention to maintain the safety of the infant 7. Adaptation of the family with an infant that was born premature, with an anomaly or that may have died before or after delivery
  • 23. 23Unit THE NURSING PROCESS AS IT RELATES TO: V 1. The physiological adaptation of the newborn after delivery to maintain homeostasis with focus on the cardio- respiratory and thermoregulatory systems 2. Behavioral characteristics of the newborn as it adjusts to life out of utero in regards to their periods of activity and reactivity and rest 3. The nutritional needs of the newborn with discussion on formula versus breast feeding as the nutritional source 4. Complications of the newborn period that relates to gestational age, Rh incompatibility, and pathological jaundice 5. Conditions of the newborn that may be the result of preexisting maternal conditions or her risk taking behaviorsUnit THE NURSING PROCESS AS IT RELATES TO: VI 1. Physical, legal, and ethical implications of a woman who have an elective abortion or a sexually transmitted disease 2. Education by the nurse on the physical effects and the importance of treatment of sexually transmitted diseases 3. Infertility and the factors that may contribute to a couple’s inability to conceive with testing for both partners 4. Psychological impact on a couple as they proceed through infertility testing and suffer interventional failures in conceiving 5. The physical and psychological effects of menopause and the controversy of treatment of the condition with hormone replacement therapy 6. Diagnostic procedures for detecting cancers of the female reproductive system 7. Teaching the client the importance of yearly screening for cervical and breast cancer as dictated by age for the latter but also proper technique for self breast examination 8. Care, medical/surgical and psychological, for the woman diagnosed with breast cancer 9. Identification of national and community resources for the woman with breast cancer that provides education, support, treatment options, and clinical trial options
  • 24. 24 UNIT 1 OUTCOMES Upon completion of UNIT 1 the student will be able to:1. Relate ovulation and ejaculation to the human process of conception.2. Explain implantation and nourishment of the embryo and development of the placenta.3. Explain structure and function of the: a. Placenta b. Umbilical cord c. Fetal membranes4. Describe fetal circulation and the circulatory changes that occur after the birth of the newborn.5. Describe normal fetal development in term of major developmental accomplishments in each trimester of pregnancy.6. Differentiate presumptive, probably, and positive signs of pregnancy.7. Describe physiological and anatomical changes that occur during pregnancy.8. Describe the psychological response of the expectant mother and father to pregnancy.9. Explain the maternal tasks of pregnancy.10. Identify the nutrient needs of the pregnant client adapting to the physical changes of pregnancy11. Identify special dietary alternatives with varying socioeconomic and cultural backgrounds.12. Describe the initial antepartum assessments in terms of: a. Medical history and physical b. Obstetrical history c. Estimated date of delivery d. Risk assessment e. Miscellaneous laboratory tests and procedures13. Identify the following in regards to fetal diagnostics: a. Purpose of the procedure b. Risks of the each procedure c. Nursing care during each14. Determine the basic teaching/learning needs of client experiencing common discomforts of pregnancy.15. Utilize the nursing process to discuss the common discomforts of pregnancy.
  • 25. 2516. Identify available educational opportunities for student/staff nurse to obtain additional knowledge about the childbearing client.17. Discuss the legal/ethical implications with regards to the care of the above mentioned clients with special needs.18. Identify the special needs of the pregnancy client during a disaster.19. Discuss the major aspects of a post-disaster perinatal assessment.20. Identify potential natural and manmade disasters. UNIT 1 ACTIVITIES Study Guide for Maternity & Women’s Health Care 10th ed. Lowdermilk, Perry, Cashion, and Alden Review the study guide for the corresponding chapters outlined under resources. Be prepared to discuss the above chapters the first day of class. UNIT 1 RESOURCES th Maternity & Women’s Health Care 10 ed. Lowdermilk, Perry, Cashion, and Alden Chapter 13 Conception and Fetal Development Chapter 14 Anatomy and Physiology of Pregnancy HO: Fetal circulation HO: Fetal Development During Each Trimester Video: The Ultimate Pregnancy Guide Chapter 16 Nursing Care During Pregnancy HO: Physiological Changes During Pregnancy Chapter 14: Maternal and Fetal Nutrition Nutrition during pregnancy and breastfeeding: http://www.nal.usda.gov/fnic/pubs/topics/pregnancy/precom.html Chapter 26: Assessment for Risk Factors Chapter 5: Violence against Women HO: Diagnostic Assessments for Fetal Status HO: Common Discomforts and Nursing carehttp://www.bioterrorism.slu.edu/nuclear.html. HO: Nursing care for the pregnant client pre and post disaster.
  • 26. 26 UNIT 2 OUTCOMES UPON COMPLETION OF UNIT 2 THE STUDENT WILL BE ABLE TO:1. Discuss the condition, treatment, and the nursing care of the following pregnancy-related complications: a. Spontaneous abortion b. Ectopic pregnancy c. Gestational trophablastic disease d. Cervical insufficiency e. Hyperemesis gravidarum f. Hypertensive disorders2. Utilize basic therapeutic communication techniques in dealing with a family experiencing pregnancy loss at various gestational ages.3. Utilize the nursing process in the management of the following health conditions during pregnancy: a. Diabetes mellitus b. Cardiovascular disorders c. Respiratory conditions d. Hematologic disorders4.Explain how disorders of the placenta listed below result in hemorrhagic condition in late pregnancy: a. Placenta previa b. Abruption placentae5. Utilize the nursing process in the management of hypertensive disorders of pregnancy.6.Discuss the nursing management of the pregnancy at risk with the following infections: a. Cytomegalovirus b. Rubella c. Herpes Simplex virus d. Hepatitis B e. Varicella zoster virus f. Group B Streptococcus g. Parvovirus B19 h. Toxoplasmosis6. Discuss Sexually Transmitted Infections.7. Discuss the issue of vaccination during pregnancy.
  • 27. 278.Discuss the incidence and identify factors that contribute to those childbearing families that are vulnerable: a. Pregnant adolescent b. Pregnant woman over the age of 35 c. Women who are HIV positive d. Pregnant women with substance abuse UNIT 2 ACTIVITIES Chapter 28: Antepartal Hemorrhagic Disorders. Chapter 27: Hypertensive Disorders in Pregnancy Chapter 38: Grieving the Loss of a Pregnancy. Chapter 29: Endocrine and Metabolic Disorders Chapter 30: Medical Surgical Problems in Pregnancy. CDC National Prevention Information Network: http://www.cdcnpin.org Chapter 7: Sexually Transmitted and Other Infections. Chapter 22: Transition to Parenthood. National Campaign to Prevent Teen Pregnancy: http://www.teenpregnancy.com http://www.hivinsite.ucsf.edu http://cdc/nchs/about/otheract/hpdata2010/2010indicators.html UNIT 2 RESOURCES DEVELOP DRUG CARDS: Zofran Phenergan Magnesium Sulfate Calcium Gluconate Terbutaline Procardia Betamethasine Tetracycline Pitocin
  • 28. 28 Methergine Hemabate Ergotrate Misoprostol UNIT 3 OUTCOMES UPON COMPLETION OF UNIT 3 THE STUDENT WILL BE ABLE TO:1. Discuss various theories of initiation of labor, such as the progesterone theory, deprivation theory, oxytocin and the uterine stretch theories.2. Identify the premonitory signs of labor.3. Differentiate true labor from false labor.4. Define the four stages of labor, including maternal behavior typically displayed during each stage.5. Explain the significance of Leopold’s maneuvers.6. Differentiate between fetal attitude, lie, and presentation.7. Relate the position of the fetal skull landmarks to fetal position and the maternal pelvis8. Identify the categories of positions of the fetus.9. Relate the station of the presenting part of the fetus to the maternal pelvis10. Discuss the nursing interventions utilized during each stage of labor: a. Assessment of labor progression b. Assessment of fetal well-being11. Identify various methods of pain relief utilized in the childbirth experience.12. Identify nursing interventions to be used to provide pain relief for childbirth.13. Identify baseline and periodic changes in fetal monitoring.14. Differentiate between reassuring and nonreassuring fetal heart patterns and nursing interventions employed to correct each pattern.15. Identify common signs of fetal distress.16. Utilize the nursing process in the management of fetal distress.17. Explain the APGAR scoring system and its significance in assessing the status of the newborn.18. Identify the immediate care of the newborn.19. Discuss independent and interdependent nursing interventions for the following high risk conditions: a. Dysfunctional labor b. Premature rupture of membranes
  • 29. 29 c. Premature labor d. Postdate pregnancy e. Ruptured uterus f. Fetal malposition and malpresentation g. Cephalopelvic disproportion(CPD) h. Prolapsed umbilical cord i. Amniotic fluid-related embolism(AFE) j. Precipitous labor & delivery k. Emergency childbirth; childbirth during a disaster.20. Explain risks, precautions, and contraindications for the following obstetrical procedures: a. Amniotomy b. Induction/augmentation of labor c. Versions d. Forcep/vacuum extractions e. Episiotomy f. Cesarean birth UNIT 3 ACTIVITIES CONTINUE WORKING ON THE CORRESPONDING CHAPTERS IN THE STUDY GUIDE UNIT 3 RESOURCES Chapter 16: Labor and the Birth Process Birthworks: http://www.birthworks.org Chapter 19: Nursing Care During Labor Chapter 17: Management of Discomfort Video: Epidural Anesthesia HO: Analgesia & Anesthesia During Labor. HO: Fetal Monitoring Video: Fetal Monitoring Chapter 24: Nursing Care of the Newborn. HO: Immediate Care of the Newborn
  • 30. 30 Chapter 31: Obstetric Critical Care Chapter 33: Labor and Birth Complications Video on Preterm Labor Video on Induction and Augmentation of Labor. UNIT IV OBJECTIVES UPON COMPLETION OF UNIT 4 THE STUDENT WILL BE ABLE TO:1. Describe the normal physiological alterations of each system occurring in the postpartum client: a. Reproductive b. Endocrine c. Cardiovascular d. Urinary e. Gastrointestinal f. Neurological g. Integumentary h. Immune2. Identify nursing interventions appropriate to sustain normal functioning during the postpartum period.3. Describe the pharmacological actions, nursing implications and contraindications of drugs commonly used during this period.4. Identify signs and symptoms of a. involution, b. subinvolution c. after pains d. engorgement e. let-down reflex f. puerperal sepsis5. Develop a plan of care, including teaching aspects related to the following physiological occurrences: a. Involution b. Subinvolution c. Autolysis d. Lochia e. After pains f. Breast engorgement
  • 31. 31 g. Let-down reflex h. Puerperal sepsis6. Recognize the signs, symptoms and risk factors for the development of each of the following postpartum complications: a. Postpartum hemorrhage(early and late) b. Thromboembolic disorders c. Postpartum infections7. Identify nursing interventions to prevent and treat the complications listed in the learning outcome above.8. Develop a plan of care for a client who had a Cesarean delivery.9. Describe effective teaching strategies for client education about birth control.10. Compare and contrast various methods of birth control according to the following criteria: a. Safety/effectiveness b. Contraindications c. Nursing responsibilities d. Advantages/disadvantages e. Expense f. Preference11. Describe the psychological dynamics of the postpartum client of various ages and her family.12. Identify factors which influence parental-infant bonding or attachment.13. Differentiate between the ways fathers and mothers interact with their infants.14. Describe the two major mental disorders that may occur during the postpartal period.15. Explain the effects on the postpartum family of a preterm infant, an infant with an anomaly, or a neonatal death.16. Discuss the role of the nurse in postpartum education.17. Describe postpartum home and community care. UNIT IV ACTIVITIES Chapter 20: Postpartum Physiology Center for Postpartum Health: https://www.postpartumhealth.com Chapter 21: Nursing care of the Postpartum Woman. HO: Postpartum Physiologic Adaptations Chapter 34: Postpartum Complications HO: Postpartum Complications Chapter 8: Contraception and Abortion
  • 32. 32 Planned Parenthood Federation of America, Inc. http://plannedparenthood.org Chapter 22: Transition to Parenthood Video: “Begin with Love, connecting with your baby” Chapter 32: Mental Health Disorders and Substance Abuse HO: Postpartum Depression Depression after Delivery: http://depressionafterdelivery.com Chapter 24: Care of the Newborn and Family. UNIT IV RESOURCES CONTINUE WORKING ON THE CORRESPONDING CHAPTERS IN THE STUDY GUIDE. DRUG CARDS TO DEVELOP: Rho-Gam Meruvax Colace Feosol Heparin Coumadin Develop pt. teaching guides for the different contraception options. UNIT V OBJECTIVESUpon completion of the UNIT 5 the student will be able to: 1. Describe the newborn’s physiological adaptation to the birth process and biologic characteristics 2. Develop interventions to maintain normal physiological functions of the newborn as it adapts to its new environment. 3. Describe the physiological response of the newborn to hypothermia and identify factors that put the neonate at risk for cold stress. 4. Describe the newborn’s behavioral characteristics in relation to periods of reactivity. 5. Describe the initial and ongoing assessments of the newborn with emphasis on the nurse’s responsibilities in the cardio- respiratory and thermoregulatory assessments. 6. Explain the importance and components of gestational age assessments. 7. Explain the risks, benefits, and the care of the newborn following circumcision. 8. Identify the nutritional and fluid needs of the newborn. 9. Compare the advantages and disadvantages of breast feeding and formula feeding.
  • 33. 3310. Explain the physiology of lactation.11. Identify criteria for referral/consultation of a breastfeeding mother to a lactation specialist.12. Explain the complications, treatments, and nursing care of infants with: a. Preterm b. Postmature syndrome c. Large for gestational age(LGA) d. Small for gestational age(SGA) e. Intrauterine growth restriction(IUGR13. Explain the causes, significances, and nursing care of the infant with: a. Pathologic jaundice b. Effects of maternal diabetes c. Effects of maternal substance d. Common congenital anomalies e. Rh incompatibility UNIT V ACTIVITIES CONTINUE WORKING ON THE CORRESPONDING CHAPTERS IN THE STUDY GUIDE UNIT V RESOURCES Chapter 24: Care of the Newborn and Family. Chapter 23: Physiologic and Behavioral Adaptations of the Newborn. DVD: Newborn Assessment Chapter 25: Newborn Nutrition and Feeding La Leche League International: http://www.lalecheleague.org Chapter 37: Nursing Care of the High Risk Newborn Chapter 35: Acquired Problems of the Newborn. Chapter 36: Hemolytic Disorders and Congenital Anomalies
  • 34. 34 UNIT VI OBJECTIVES UPON COMPLETION OF UNIT 6 THE STUDENT WILL BE ABLE TO:1. Discuss the condition, effects, management and nursing care of the woman experiencing a spontaneous and an elective abortion.2. Explore the legal/ethical implications in the client having an elective abortion.3. Discuss the physical effects of the client with sexually transmitted infection(STI).4. Discuss the nurse’s legal/ethical role in the care for a client with a STI with focus on privacy laws.5. List educational opportunities for health care providers related to STIs and pregnancy.6. Describe teaching to prevent and control STIs.7. Define infertility and explain factors that may cause it.8. Identify specific evaluations, procedures, and treatment for the couple that is unable to conceive.9. Describe the physical and psychological changes associated with menopause.10. Discuss the risks versus the benefits of hormone replacement (HRT).11. Identify basic teaching/learning principles determining the learning needs of clients going through menopause.12. Discuss the nursing implications in the following cancer diagnostic procedures: a. Tumor markers b. Cytologic tests c. Mammogram d. Biopsies13. Discuss breast and ovarian cancers in females.14. Discuss the importance and proper technique of self-breast examination (SBE).15. Identify individuals that are at risk for developing breast cancer.16. Identify specific medical therapies and surgical interventions for breast cancer.17. Identify resources available to the student and the staff to remain current on knowledge related to the care of the adult client with cancer.18. Identify community resources available for the client who has had a mastectomy.19. Discuss options available to the mastectomy client regarding breast reconstruction. Identify and discuss appropriate nursing diagnoses for each type of cancer.20. Discuss the nurse’s role in managing care according to prioritized client needs
  • 35. 35 UNIT VI RESOURCESChapter 8: Contraception and AbortionChapter 7: Sexually Transmitted and Other Infections.Center for Disease Control and Prevention: http://www.cdc.govChapter 9: InfertilityHO: InfertilityChapter 6: Reproductive System Concerns.Chapter 11: Structural Disorders and Neoplasm’s of the Reproductive System.Chapter 10: Problems of the BreastReach to Recovery though the American Cancer Society: http://www.cancer.orgSusan G. Komen Breast Cancer Foundation: http://www.komen.orgLiving Beyond Cancer: http://Ibbc.org
  • 36. 36 REQUIRED TEXTBOOKSBerman, A., Snyder, S.J., Kozier, B. & Erb, G. (2012). Kozier & Erb’s Fundamentals of NursingConcepts, Process and Practice. (9thed.). Upper Saddle River, NJ: Prentice Hall.Kee, J. L., Paulanka, B. ., Purnell, L .D. (2010). Fluids and electrolytes with clinical applications: A programmed approach, (8th ed.).Clifton Park, New York: Thomson/Delmar Learning.Lehne, R. A. (2010). Pharmacology for nursing care. (7th ed.). St. Louis: Saunders.LeMone, P., & Burke, K. M. (2011). Medical surgical nursing: Critical thinking in client care. (5th ed.). Upper Saddle River, NJ:Prentice Hall.LeMone, P., & Burke, K. M. (2011). Study guide for medical surgical nursing: Critical thinking in client care. (5th ed.). Upper SaddleRiver, NJ: Prentice Hall.REQUIRED TEXTBOOK:1. Lowdermilk D., Perry S., Cashion K., Alden K. (2012). Maternity & Women’s Health Care. (10th ed.). St Louis: Missouri.Mosby/Elsevier.2. LeMone P. and Burke K.M. (2010). Medical-Surgical nursing: Critical thinking in client care. (4th ed.). New York: Prentice Hall,Inc.3. Lehne, R.A. (2010). Pharmacology for nursing care. (7th ed). St. Louis: W.B. Saunders.4. Kee, J.L., Paulanka, B.J., and Purnell, L.D. (2010). Fluids and electrolytes with clinical applications: A programmed approach. (8thed). Clifton Park: New York. Thompson learning, Delmar.1. Lowdermilk D., Perry S., Cashion K., Alden K. (2012). Study guide for Maternity & Women’s Health Care. (10th ed.). St Louis:Missouri. Mosby/Elsevier.2. Lehne, R.A. (2010). Study guide: Pharmacology for nursing care. (7th ed). St Louis: W.B. Saunders.4. Any current (20011) text pertaining to laboratory and diagnostic testing.
  • 37. 37January 11, 2012Re: Clinical Spring 2012 thClinical orientation: All groups to meet at designated site at 2:45 P Friday the 13 . Bring TCPS papers and the proof of TB; CPR; etc. Dress is business casual with lab coat and ID’s. Bring syllabus with signature forms ready to submit toinstructor. NO RECORDING or PICTURES ANYWHERE ON CLINICAL GROUNDS. We will review this information in clinical orientation. Please make 2 copies ofthis as one copy will need your signature of understanding and submitted with your other papers.Baptist Women’s: meet at fountain in front lobby:Wednesday group: Kurt Amelang; Elizabeth Bruno; Sonia Gemora-Garrett; Jocelyn Jones; Anthia Jordan; Kari McLean; Dorice ShikhuleFriday group: Carrie Emerson; Ashley Gafa; Stacy Johnson; Lauren Lancaster; Georgia Leeper; Karen Otts.The Med: meet in the lobby of the newborn center: (After the hospital portion you will then need to come over to the Women’s Hospital where we will goover the paperwork etc. Plan to meet at the front lobby waterfall at 5:30pm).Friday group: Pat Allen; Jessica Bryan; Lacey Delee; Laquita Griffin; Saira Hussain; Amber McNabb; Jessica WalkerSaturday Group: James Dabbs; Ana-Maria Ferro; Merry Mattix; Kimberly Mitchell; Pamela Moore; Stacie Wilkins; Maresha Woodson-WalkerActivity sheets are due before the start of clinical on the assigned due dates. They must be turned in complete at the beginning of clinical before studentassignments are made, if not complete, you will not be prepared for clinical and will be sent home. th th st L&D and AP will be due on the 18 /20 /21 – which ever your clinical day falls on. (Ex: if your clinical day is Wednesday, then your paperwork is due on the th18 ) st rd thNew Baby and Postpartum is due on the 1 /3 /4 -again on the actual day your clinical falls on.General Expectations: th th stEach week 2 APIE’s will be due by the start of class on Tuesday’s. (Ex: clinical databases (found in your syllabus) from the 18 /20 /21 will be used to form thyour APIE’s, and those APIE’s will be due on Tuesday the 24 at 9:10 am.).Please get a folder that will be designated for clinical: a copy of your evaluation (found in your syllabus), all patient data sheets and all APIE’s must be kept inthe folder and turned in each week. The activity sheets will need to be turned in with your folders at the end of your clinical. We will cover this again duringface to face clinical orientation. I know it sounds very overwhelming, but we will all get through it together. Ms. Overbey, Ms. Bullard, Ms. Vaughn-Lloyd and Iare here to guide you through your learning experiences. We all also remember the stresses of being in nursing school!Cell phones are not allowed in clinical. This includes your pockets!Even if you do not usually eat in the mornings, please eat something!! Bring snacks; we don’t want to miss a delivery because we left the floor to eat! Believe itor not, this is an area where it is not uncommon to PASS OUT!!! Please, if you ever feel light headed, sit where you are, those who quickly try to leave theroom…HIT THE FLOOR! :-/Be on time; dressed in school approved shirt and pants and your lab coats; don’t forget your stethoscopes, pen lights or scissors (see syllabus); and always haveyour student ID. The clinical sites will not allow you to stay if your do not have your ID’s.Remember, never, never, never, leave the clinical area without first notifying your instructor and the nurse assigned to your patient. Even to go to lunch. Andleaving the clinical site to go to lunch is not allowed.Remember, our particular patients are often very sensitive to odors, good and bad! No perfumes, but please do pay special attention to your daily hygienehabits, including dental hygiene ;). thPlease review and submit proof of the following programs: (copy the evaluation page): by beginning of class on Tuesday the 17 .1.http://www.urmc.rochester.edu/ob-gyn/education/peri-facts/
  • 38. 38(Click on the “Peri-Facts subscribers only” as pictured)Username: STCC-TN-01Password: MOTHER (typed in ALL CAPS)2.http://www.orlive.com/shawneemission/videos/cesarean-section-birthThis is approx 30 minutes. Please view and take a screen shot of the end. (You will need to pause it to print off the screen shot.)Again, please do not get overwhelmed. (Try). I am looking forward to meeting and working with all of you! Welcome to NCBF!Mrs. JonesMy Cell # is 828-8865 & I have texting, if there is any pressing questions or concerns that cannot wait until class or clinical orientations.

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