Things I Should Probably Know Flashcards
What abnormal lab values confirm the diagnosis of HELLP?
- Urine protein consistent with pre-e
- Schistocytes on blood smear
- Platelets less than 100k
- TBili greater than 1.2
- AST greater than 70
What is HELLP?
Believed to be a form of pre-E
Hemolysis (H)
Elevated liver enzymes (EL)
Low platelet count (LP)
APGAR assesses which 5 things?
Neonatal HR Resp effort Muscle tone Reflex irritability Color
0-2 points per each category, 10 is best score
Abruptio placentae
Onset of symptoms: sudden and intense bleeding with pain
Bleeding may be vaginal or concealed
Uterine tone is FIRM
Placenta Previa
Onset of symptoms: asymptomatic or painless bleeding
Vaginal bleeding
Uterine tone is soft and relaxed
Metformin is contraindicated with?
IV contrast (hold metformin for at least 48 hours after receiving IV contrast)
Cranial nerve 1
Olfactory
Controls sense of smell
Cranial nerve 2
Optic
Central and peripheral vision
Cranial nerve 3
Oculomotor
Constriction of pupils
Cranial nerve 4
Trochlear
Downward eye movement
Cranial nerve 5
Trigeminal
Face
Cranial nerve 6
Abducens
Sideways eye movement
Cranial nerve 7
Facial
Movement and expression
Cranial nerve 8
Vestibulocochlear
Controls hearing
Cranial nerve 9
Glossopharyngeal
Tongue and throat
Cranial nerve 10
Vagus
Sensory and motor
Cranial nerve 11
Accessory
Head and shoulder movement
Cranial nerve 12
Hypoglossal
Tongue position
Nasal fracture
Most common of all facial fractures and least likely to need specialist consult
Orbit rim and blowout fracture
Fractures of orbital floor or lateral and medial orbital walls; occur from direct blow to orbit such as from a baseball or fist
Mandibular fractures of the lower jaw
May be singular or multiple
Maxillary fractures
Fractures of the upper jaw
Le Fort 1, 2, and 3
Le Fort I
Horizontal fracture, separates teeth from upper structures
“Floating palate”
Le Fort II
Pyramidal fracture; teeth are at the base of the pyramid, fracture passes diagonally along the lateral wall of the maxillae sinuses, apex of pyramid is the nasofrontal junction
“Floating maxilla”
Le Fort III
Craniofacial disjunction transverse fracture line passes through the nasofrontal junction, maxillofrontal suture, orbital wall, zygomatic arch, and zygomaticofrontal suture
“Floating face”
“Floating palate”
Le Fort I
“Floating maxilla”
Le Fort II
“Floating face”
Le Fort III
Zygomaticomaxillary complex (tripod) fractures
Simultaneous fracture of the lateral and inferior orbital rim, the zygomatic arch, and lateral maxillary sinus wall
Occurs from direct blow to the lateral cheek
Blast lung injuries (BLI): clinical triad
Apnea
Hypotension
Bradycardia
The 6 P’s
Pain Paresthesia Pallor Paralysis Pulselessness Poikilothermia
Compartment syndrome: compartment pressure
Within 20-30mmHg of mean arterial pressure
Non displaced fracture
Broken area of bone remains in alignment
Optimal condition for reduction and healing
Displaced fracture
Broken areas of bones are not aligned
May require manual or surgical reduction including hardware for fixation
Transverse fracture
Horizontal break in a straight line across the bone occurs from a force perpendicular to the break
Oblique fracture
Diagonal break occurs from a force higher or lower than the break
Spiral fracture
Torsion or twisting break around the circumference of the bone
Common in sports injuries and abuse
Comminuted fracture
Break is fragmented into 3 or more pieces.
More common in people older than 65 and those with brittle bones
Compression fracture
Break is crushed or compressed, creating a wide, flattened appearance
Frequently occurs with crush injuries
Segmental fracture
Two or more areas of the bone are fractured, creating a segmented area of “floating” bone
Greenstick fracture
Type of incomplete break
Bone is not completely separated and bends to one side; common in children due to softer bones
Avulsed fracture
A “chip” fracture displaced small segments of bone from the main bone at the area of tendon/ligament attachment. Results from tension/pulling of the tendons/ligaments away from the bone
Torus/buckle fracture
Incomplete fracture with bulging of cortex, common in children
Impacted fracture
Ends of the bone are impacted or “jammed” into each other from forceful impact
Salter-Harris fracture
Growth plate fracture
Classified as I-V
Estimated blood loss from pelvic fractures
1.5-4.5L
Estimated blood loss from hip fracture
1.5-2.5L
Estimated blood loss from femur fracture
1-2L
Estimated blood loss from humerus fracture
1-2L
Fractures with risk for fat emboli (4)?
Comminuted fractures of femur or tibia
Fractures of ribs or pelvis
Trephination
Boring of hole into the nail bed to relieve the underlying pressure
Rule of 9’s
For calculating TBSA for burns
Face: 9% (4.5% front, 4.5% back) Chest/abd front: 18% Back: 18% Arm: 9% EACH (4.5% front, 4.5% back) Groin: 1% Legs: 18% EACH (9% front, 9% back)
1st degree burn
Affects DERMIS only
Reddened area
Blanches easily with light pressure
Think sunburns
2nd degree burns: superficial partial thickness
Blanches with pressure
Development of vesicles or bullae in 24 hours
Often appear wet
2nd degree burns: deep partial thickness
Color is white or red
Does NOT blanch
Often appears dry
Development of vesicles or bullae
3rd degree burns
Vary in appearance: white, red, black and charred, brown and leathery
No pain or reduced pain d/t nerve damage
No development of vesicles or bullae
Hypovolemia (hypotension or whole body edema)
Metabolic acidosis
Rhabdo
Hemolysis
AKI
Parkland formula
Calculates fluid resuscitation for burns
2-4mL x TBSA (%) x weight in kg
Give 50% in first 8 hours, remaining in next 16 hours
—formula time starts at the time the burn happened
USE LACTATED RINGERS NOT NS
What kind of salve should be used on burns?
Silver salve
Patient sustained burns. Burns are eschar and constricting. What procedure is indicated?
Escharotomy
Which form of intubation is to be avoided in ingestion & inhalation burns?
Nasotracheal intubation
Consider cricothyrotomy
What should not be administered before antivenom in snake bites?
Blood products
Keraunoparalysis
Weakness in limbs following a lightning strike
Lightning strike differs from generated electric energy in that it does not usually cause which 3 things?
Burns
Rhabdo
Internal organ/tissue damage
Decon: radiation
Use radiation meter to monitor progress
Remove clothing and debris
Decon skin
Clean wounds before intact skin using NS
Internal decon for radiation: which 3 drugs are used?
Potassium iodine (KI) Prussian blue Diethylenetriamine pentaacetate (DTPA)
Prussian blue
Used for internal radiation decon
Removes radioactive cesium and thallium from body.
Radioactive material is passed in the feces
Oral med
Diethylenetriamine pentaacetate (DTPA)
Removes radioactive plutonium, americium, and curium from the body
Radioactive material is passed in the urine
Can be given IV or as an inhalant for those who have inhaled radiation
ABG analysis in submersion injuries reveals?
Significant metabolic acidosis (pH < 7.35 and HCO3 < 22)
Resuscitation in drowning victims starts with _________ _________ and not ________________.
Rescue breathing; compressions
Treatment of __________ is the main concern in submersion injuries.
Hypoxemia
Hypoxemia treatment in submersion injuries
Intubate
Start patient on 100% O2, titrate down based on serial ABGs
Use PEEP
Administer nebulized bronchodilators to relieve bronchospams or wheezing
CXR
Hypothermia occurs when core body temp drops below ____.
35°C (95°F)
When body temperature drops below _____, thermoregulation ceases.
30°C (86°C)
Ekg readings in hypothermia
Very important
Shows prolonged intervals
Will read as injury due to MI, but will show a J wave or Osborn wave
Treatment of mild hypothermia
Passively rewarm patients at a rate of 1°C per hour with an insulated blanket and rewarmed fluids
Use active rewarming with forced hot air in an enclosure
It’s better to apply the heat to the core of the body. Heat applied to the extremities may increase metabolic demand, which can strain the depressed cardiovascular system
Treatment of severe hypothermia
Treat with active core warming
Inhalation: O2 should be heated to 40°C-45°C (104-113°F) and delivered via oxygen mask or ET tube
Infusion: IVF or blood products should be heated to 40-42°C (104-107.6°F)
Lavage: closed thoracic lavage can be administered through 2 thoracic tubes; the peritoneal lavage should be heated 40-45°C
Extracorporeal core rewarming: not often performed
Fluid resuscitation: administer 1-2L for adults or 20mL/kg for peds of NS heated to 40-42°C
Moderate hypothermia temps
28-32°C (82.4-89.6°F)
Severe hypothermia temps
Less than 28°C (82.4°F)
Cardiovascular involvement of hypothermia
CPR is only administered in patients with a perfuming rhythm when true cardiac arrest is confirmed
Patients who have VF or asystole require CPR
Defib is only recommended once body temp reaches about 30°C (86°F)
Administration of ACLS drugs should not be expected
Defib (in hypothermia) is only recommended once body temp reaches about ______.
30°C
Examples of anticholinergic meds (and one plant for bonus points)
Antihistamines
Antipsychotics such as haldol, seroquel, and zyprexa
TCAs such as amitriptyline
Benztropine
Scopolamine
Atropine
Atropa belladonna (deadly nightshade)
S/s anticholinergic toxicity
Hyperthermia (“hot as a hare”) Flushing (“red as a beet”) Mydriasis, blurred vision (“blind as a bat”) Dry skin (“dry as a bone”) Agitation, delirium, hallucinations, memory loss (“mad as a hatter”) Urinary retention (“full as a flask”) Tachy HTN Ileus
Treatment for anticholinergic toxicity
Physostigmine salicylate
Supportive care for s/s (benzos for seizures, Valium for agitation, catheter for retention, cooling measures for hyperthermia)
Cholinergic crisis
Result of excess acetylcholine, which causes overstimulation of muscarinic and nicotinic receptors
Most common causes of cholinergic crisis
Anticholinesterase (patients with MG, patients who have received neostigmine after gen. anesthesia)
Insecticides and pesticides
Nerve agents (ex: sarin)
S/s cholinergic crisis: generalized
HR, BP, and RR may be increased or decreased
Increased bowel sounds
Constructed pupils
Diaphoresis
Muscarinic s/s (cholinergic): SLUDGE
Salivation Lacrimation Urination Defecation GI cramps Emesis
Muscarinic s/s (cholinergic): DUMBELS
Diarrhea Urination Miosis Bronchorrhea, bradycardia, bronchoconstriction Emesis Lacrimation Salivation
Nicotinic s/s (cholinergic): MTW(T)hFS
Mydriasis Tachycardia Weakness HTN, hyperglycemia Fasciculations Sweating
(Also abd pain, paresis)
Treatment and management of cholinergic crisis
Decon patient if needed (pesticides)
Maintain airway and breathing
IVF
Antidote (atropine, oximes like pralidoxime)
Supportive care for symptoms (like benzos for seizures)
Antidotes for cholinergics
Atropine
Oximes (ex: pralidoxime)
Sympathomimetic agents: how do they work?
Mimic endogenous sympathetic nervous system agonists (like epi and dopamine), causing direct stimulation of the alpha and beta adrenergic receptors
Examples of sympathomimetics
Cocaine Amphetamines Methamphetamines MDMA Bath salts Cold meds (like Sudafed) Diet supplements containing ephedrine
Ingestion of acids will cause?
Injuries to the upper resp. tract as the pain and sour taste prompt gagging or spitting, which may lead to aspiration
May also cause coagulative necrosis in the stomach
Alkali ingestion causes?
Liquefactive necrosis in the esophagus and will continue to cause damage until it has been neutralized
S/s acid/alkali ingestion
Drooling Dysphagia Visual oral burns Emesis (can appear brown) Bleeding in mouth, throat, or stomach Excessive thirst
Esophageal perf.
Airway injury
Treatment of acid/alkali burns in first few minutes after ingestion?
Dilute with milk or water
Treatments contraindicated with acid/alkali ingestion
Gastric emptying by emesis* Activated charcoal Neutralizing agents Gastric lavage NG tube
*This is because the acid/alkali is a caustic agent and causing regurgitation will re-expose the upper GI tract to the caustic agent
Valium dosing for CIWA score of 8-14
5-10mg or equivalent Ativan (0.5-1mg)
Valium dosing for CIWA score of 15-19
10-15mg Valium or equivalent
Valium dosing for CIWA score of 20-25
20mg Valium or equivalent
Valium dosing for CIWA score of 25-30
25-30mg Valium or equivalent
Cyanide antidotes (4)
Hydroxocobalamin
Amyl nitrite
Sodium nitrate
Sodium thiosulfate
Sources of cyanide
Smoke from fires
Meds (sodium nitroprusside)
Pits/seeds from bitter almonds, apricots, peaches, and apples
S/s cyanide poisoning
Bitter almond smell on breath HA Confusion Bloody emesis Diarrhea Flushed, red skin Tachy HTN Tachypnea Hypovolemic shock Coma
Which diseases require the use of airborne precautions (4)?
Measles
Chicken pox
Herpes zoster BEFORE blisters are completely dry and crusted
TB
Which diseases require the use of droplet precautions (5)?
Measles Mumps Pertussis Chicken pox Diphtheria
Which diseases require the use of contact precautions (7)?
C.diff Chicken pox Diphtheria Mono Herpes zoster BEFORE blisters are completely dry and crusted MRSA VRE
s/s opioid OD
resp depression shallow breathing pinpoint pupils cyanosis bradycardia change in LOC
treatment/management of opioid OD
narcan (naloxone) is reversal agent
intubate for airway protection if indicated
mechanical ventilations
s/s acetaminophen OD
Gastroenteritis
Renal failure
pancreatitis
hepatotoxicity leading to multiple organ failure
treatment/management of acetaminophen OD
n-acetylcysteine (mucomyst) is treatment for OD
activated charcoal if in window for administration
nursing considerations for acetaminophen OD
monitor serum acetaminophen levels in labs (dosing for mucomyst is based on these serial results)
s/s salicylate OD
N/v tinnitus fever confusion seizures rhabdo acute renal failure hyperventilation & resp alkalosis (EARLY) hypoventilation and resp acidosis (LATE) resp failure hyperactivity that can turn into lethargy
treatment/management of salicylate OD
activated charcoal
alkaline diuresis with extra KCl
ETT if indicated
mechanical ventilation if needed
nursing considerations for salicylate OD
draw salicylate levels & ABGs
examples of salicylates
aspirin (ASA)
ibuprofen
other NSAIDS
s/s calcium channel blocker OD
Hyperglycemia Hypotension Bradycardia Heart block peripheral edema reflexive tachycardia
treatment/management of calcium channel blocker OD
High dose insulin
Vasopressors
Inotrope
nursing considerations for calcium channel blocker OD
ekg
frequent monitoring of BP
monitor BG
examples of calcium channel blockers
amlodipine diltiazem nicardipine nifedipine verapamil
s/s beta blocker OD
cardiac:
- bradycardia
- hypotension
- prolonged QT interval
- prolonged QRS complex
- ventricular dysrhythmias
- AV block
GI:
- esophageal spasms
- hyperkalemia
- hypoglycemia
treatment/management of beta blocker OD
glucagon
dopamine, norephinephrine
ipratropium for pts with esophageal spasms
examples of beta blockers
the “-olols”
metoprolol
atenolol
propranolol
s/s digitalis OD
n/v abd pain HA dizziness confusion HALO VISION bradycardia tachydysrhythmias (paroxysmal atrial tachycardia with block most common)
treatment/management of digitalis OD
digoxin immune fab
potassium supplementation
atropine in case of AV block or severe bradycardia
lidocaine or phenytoin to prevent cardioversion
nursing considerations for digitalis OD
continuous telemetry monitoring as hyperkalemia could lead to AV block
s/s heavy metal OD
altered LOC fatigue muscle and joint pain HTN constipation numbness & pain in extremities dark eye circles hearing loss
Mees’ lines
- white lines running across the entire nail bed
- but can also be indicative of other conditions
severe lead toxicity will lead to?
wrist drop
encephalopathy
colic
Burton’s lines (blue-black line on gums)
mercury poisoning can lead to?
“mad hatters disease” with s/s including slurred speech, irritability, and depression
treatment/management of heavy metal OD
chelation therapy
dialysis
most common metals in heavy metal OD?
arsenic
cadmium
lead
mercury
s/s iron OD (5 stages)
stage 1: GI upset, n/v, pain
stage 2: latent phase; milder GI upset
stage 3: shock and metabolic acidosis, dehydration, lactic acid
stage 4: hepatotoxicity, necrosis
stage 5: bowel obstruction from GI healing leading to scarring
treatment/management of iron OD
deferoxamine mesylate (DFO) for acute iron toxicity
intermittent phlebotomy for chronic iron toxicity from hemochromatosis
-this helps lower ferritin and may reduce s/s too much iron
nursing considerations for iron OD
especially toxic in children (consuming chewable vitamins)
can be seen in patients who have had repeated blood transfusions
s/s oral hypoglycemic OD
mild: dizziness, nausea, lightheadedness
severe: altered LOC, CNS depression, seizures, coma, hypokalemia, hypomagnesemia
treatment/management of oral hypoglycemic OD
sulfonylurea supplemented with octreotide if needed for GI symptoms
IV dextrose bolus followed by D10 continuous infusion
s/s warfarin OD
bloody, red, or black tarry stool
pink, red, or dark urine
spitting up or coughing up blood
“coffee ground” emesis
hemorrhage
treatment of warfarin OD (think of reversal agent)
vitamin K
s/s TCA OD
blurred vision, dilated pupils, lethargy, change in LOC, hallucinations, hyperthermia, seizures, resp. distress, hypotension, tachycardia, cardiac arrest
treatment/management of TCA OD
sodium bicarb
metoprolol as needed to correct cardiac dysrhythmias
benzos for seizure treatment
Airborne precautions
Private room with negative pressure air system
Door kept closed
N95 required
Droplet precautions
Private room, door may be open
Appropriate PPE within 3 feet of patient
Wash hands with antimicrobial soap after removing gloves and mask, before leaving the patient’s room
Surgical mask
Contact precautions
Private room, door may be open
Wear gloves, gown
Hand hygiene
Which diseases require the use of airborne precautions (4)?
Measles
Chicken pox
Herpes zoster BEFORE blisters are completely dry and crusted
TB
Which diseases require the use of droplet precautions (5)?
Measles Mumps Pertussis Chicken pox Diphtheria
Which diseases require the use of contact precautions (8)?
C.diff Measles Chicken pox Diphtheria Mono Herpes zoster BEFORE blisters are completely dry and crusted MRSA VRE
Meds to treat cdiff
Metronidazole (flagyl)
Vancomycin
Fidaxomicin (Dificid)
In refractory or severe cases of cdiff, which 2 procedures may be used?
Fecal transplant
Colectomy
Measles
Infection caused by a paramyxovirus
Virus enters through upper resp react or conjunctiva and spreads systemically through lymph nodes, triggering a systemic inflammatory response
Spread through resp droplets (like coughing/sneezing)
S/s: sore throats, fever, cough, runny nose, Koplik spots, rash
Dx: swab, saliva, or blood samples tested for measles specific immunoglobulin (IgM)
Tx: supportive care, give vitamin A
Mumps
Acute inf caused by a paramyxovirus. Virus enters the nose or mouth and replicates in resp tract, GI tract, or eyes. Inflamm response results in swelling of salivary glands (usually parotid gland)
Spread through resp droplets in close proximity
S/s: HA, salivary gland edema, parotitis, fever, anorexia
Dx: serological assay on blood sample to detect IgM
Tx: supportive care, isolate until glandular swelling is gone, soft diet, avoid acidic substances
Complications of measles
Subacute sclerosing panencephalitis Encephalitis Acute thrombocytopenia purpura Bacterial superinfection Transient hepatitis
Complications of mumps
Orchitis or oophoritis
Meningitis or encephalitis
Pancreatitis
Pertussis
Caused by bacterium borderella pertussis. Inf causes mucopurulent sanguineous exudate that can compromise resp tract. Initially starts with nonspecific URI s/s and progresses to a hallmark paroxysmal it’s spasmodic cough that ends in a prolonged high pitched inspiration (the “whoop”)
Spread through close contact resp droplets
S/s: cough increasing in severity, increase in mucus, n/v, nocturnal cough, hoarseness, “whooping cough”, choking spells in infants
Dx: nose/throat swab; PCR rest run on swab is most sensitive
Tx: abx (erythromycin, azithromycin); supportive care
Chicken pox
Caused by varicella zoster virus. Inhaled droplets infect conjunctiva or mucus membranes of upper resp tract. Viral inf then spreads, causing hallmark rash
Spread through direct contact and airborne droplets
S/s: itchy rash that forms small fluid-filled blisters they eventually scab; rash starts on face and trunk and spreads; fever, HA, fatigue
Dx: varicella titer test; Tzanck test (swab of lesion)
Tx: symptomatic treatment aimed at stopping itching
Tx in immunocompromised or severe cases: antivirals (valcyclovir, acyclovir)
Diphtheria
Caused by bacterium corynebacterium diphtheriae. Bacteria gains entry through pharynx or skin and releases a toxin that causes inflamm and necrosis of infected area.
Spread through resp droplets and skin contact
S/s:
- pharyngeal inf: white or gray glossy exudate in the back of the throat, edema/visibly swollen neck, stridor, serosanguinous or purulent discharge
- skin inf: often indistinguishable from symptoms that look like a variety of chronic skin inf; pain and tenderness
Dx: pharyngeal swab shows gram+ bacilli; skin swab/biopsy shows gram+ bacilli
Tx:
- pharyngeal inf: abx (PCN, erythromycin)
- skin inf: clean w/ soap and water, abx (PCN, erythromycin)
Diphtheria complications
Severe prostration Pallor Tachy Acute renal failure Stupor Coma
Main critical s/s that can develop:
- myocarditis
- nervous system toxicity
What should be administered once a patient has recovered from diphtheria?
Diphtheria vaccine
Should close contacts in diphtheria receive antibiotics?
Yes
Herpes zoster
Aka shingles
Acute viral inf that is the result of the varicella zoster virus reactivating in a posterior dorsal root ganglion
Spread through contact with fluid from blisters caused by rash
S/s: redness and rash of blisters
- usually occur in a linear fashion on one side of the body, usually appear in truncal area
- pain, itching
Dx: based on symptoms; Tzanck test from swab of lesion
Tx: antivirals (acyclovir, famciclovir, valcyclovir)
What can be used to treat the pain from shingles?
Systemic pain treated with gabapentin
Local pain treated with capsaicin or lidocaine ointment
Mononucleosis (mono)
Infection caused by Epstein Barr virus. Virus replicated in epithelial cells of pharynx and in B lymphocytes, triggering a response from the body’s immune system.
Spread through body secretions, most commonly though saliva when kissing
S/s: fatigue lasting weeks to months, fever, pharyngitis, palatal petechiae, splenic rupture, airway obstruction
Dx: blood test
Tx: supportive care, corticosteroids for severe s/s like airway obstruction
Specific teaching for mono at d/c?
Rest
Avoid heavy lifting and contact sports for 1 month or until splenomegaly resolves
Due to risk of splenic rupture, avoid _____ ________ _________ of the abd in mono.
Deep pressure palpation
MRSA is resistant to which family of abx? Give 5 examples
Beta-lactam abx
Ampicillin Amoxicillin Methicillin PCN Cephalosporin
Which abx can be used for MRSA infections (4)?
Trimethoprim (Primsol)
Sulfamethoxazole (Bactrim)
Clindamycin (Cleocin)
Linezolid (Zyvox)
VRE is resistant to which abx?
Vancomycin
VRE that can be used to treat VRE infections (6)?
Amoxicillin Amoxicillin Gentamicin PCN Piperacillin Streptomycin
Diagnostic test for TB?
Skin test (Mantoux skin test)
- positive results indicate pt is infected
- tests do not distinguish patent TB inf from active TB disease
CXR shows multinodular infiltrates near clavicle
Sputum sample shows acid fast bacilli
Treatment for TB?
2 months of tx with:
- isoniazid (INH)
- rifampin (RIF)
- pyrazinamide (PZA)
- ethambutol (EMB)
After 2 months of tx, PZA and EMB are discontinued. INH and RIF are continued for another 4-7 months or longer, depending on clinical findings and symptoms.
4 steps to disaster management and preparedness
- Mitigation
- Preparedness
- Response
- Recovery
Mitigation
Identify vulnerabilities to threats or weaknesses in current plan
Preparedness
Develop mutual aid agreements, create disaster management plans, determine supply thresholds and needs, consider stockpiles, and establish a command and control structure
Response
Warn (notify), isolate (during the disaster), and rescue (following the disaster)
Recovery
Inventory supplies and resources, relieve staff members present during the isolation phase, incorporate records into the EMR, implement CISM program if needed, and activate employee assistance programs if needed.
Which 4 elements must be present in order to prove negligence?
- duty
- breach of duty
- proximate cause
- damages
