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Vol. 19, No. 10, OCTOBER 2002
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Group Seeks to Enhance Advanced Practice Resources
Across the Continuum of Care: Many Factors Dictate Progressive Care Resource Needs
Grants
Strengthening Practice: Research Work Group Builds on Success
Research Corner: Myth Versus Reality: Follow Guidelines When Measuring Blood Pressure
Applications for 2004 Distinguished Research Lecture Award Due Dec. 1
Practice Resource Network
AACN Clinical Pocket References Now Available for PDAs
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Group Seeks to Enhance Advanced Practice Resources
Members of the 2003 Advanced Practice Work Group are
(from left, foreground) Angela Nelson, Patricia Gonce Morton
and Linda Bell and (from left, standing) Deborah Greenlaw,
Mary Tierney, Janice Powers, Linda Griego Martinez, Janie
Heath, Paula Lusardi and Lisa Kohr.
By Patricia Gonce Morton,
RN, PhD, ACNP, FAAN
Chair, Advanced Practice Work Group
Developing and compiling resources to support advanced practice nurses is the charge before the 2003 Advanced Practice Work Group, which met in August in Costa Mesa, Calif. The group’s work will be concentrated in three areas:
• Recommending topics for the 2003 Advanced Practice Institute, which is scheduled in conjunction with AACN’s National Teaching Institute and Critical Care Exposition, May 17-22, in San Antonio, Texas
• Reviewing and updating Web resources for advanced practice nursing
• Reviewing and making recommendations for catalog, online and journal support for advanced practice nursing
AACN volunteers and staff work together to implement initiatives within the AACN strategic plan and discuss ideas about acute and critical care nursing that may shape future initiatives related to advanced practice nursing. In preparation for its work, the group reviewed AACN’s operational and strategic plans with representatives of AACN’s national leadership and national office team. Janie Heath, RN, MS, CCRN, ACNP, ANP, the AACN Board of Directors liaison to the Advanced Practice Work Group and Linda Bell, RN, MSN, clinical practice specialist at the AACN National Office, presented activities currently under way. AACN President Connie Barden, RN, MSN, CCNS, CCRN, President-elect Dorrie Fontaine, RN, DNSc, FAAN, and CEO Wanda Johanson, RN, MN, addressed the priorities for AACN.
This volunteer work group model provides AACN a special link to members, with all members of the Advanced Practice Work Group involved in some aspect of acute or critical care nursing. In addition, inviting members who represent a broad scope of advanced practice nurses was a priority. For example, the work group members include clinical nurse specialists and nurse practitioners who work in hospitals, as faculty or in private practice.
The number of highly qualified AACN members who responded to the annual Call for Volunteers was exciting, though it made the process of choosing only six new members for this year a challenge. Because the group’s work would be continuing the dialogue around issues discussed by the previous year’s work group, two members of the 2002 advanced practice work group, Deborah Greenlaw, RN, MS, CCRN, and me, were invited to continue as members of the 2003 group. Other members of the group for 2003 are Lisa Kohr, RN, MSN, CCRN, PNP, Paula Lusardi, RN, PhD, CCRN, CCNS, Linda Griego Martinez, RN, MSN, CCRN, CS, Angela Nelson, RN, MSN, CCRN, ACNP, Janice Powers, RN, MSN, CCRN, CCNS, and Mary Tierney, RN, MSN, CCRN, ANP.
Serving as chair of the 2003 Advanced Practice Work Group is truly an honor. As a member of AACN for 25 years, I have had the privilege to be involved in many committees at the chapter and the national levels. I know that AACN values the work of its volunteers and greatly appreciates the help of the Advanced Practice Work Group in guiding AACN’s initiatives related to advanced practice nursing—a vital priority to our organization.
Even as a veteran volunteer, I always feel a sense of pride after leaving an AACN meeting. I am truly proud to be a member of an organization that continually seeks input from those of us it is committed to support. AACN is our organization to shape, to serve, and to support.
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Across the Continuum of Care: Many Factors Dictate Progressive Care Resource Needs
By Susan Helms, RN, MSN, CCRN
Progressive Care Task Force
Determining the resources needed to support and enhance the delivery of care to critically ill patients in the progressive care unit requires assessment of the patient population, environment and available technology.
One helpful tool when setting up a PCU is to first establish admission, discharge and transfer criteria. This criteria can guide the selection of resources and technology needed to care for the defined patient population and support cost justification for resources that may be requested.
The admission and discharge criteria should be a multidisciplinary, descriptive tool that explains the level of patient acuity that will be accommodated in the PCU. Defining and describing standards, the environment and staff responsibilities are other tools that may be useful in planning the unit.1
The Patient Population
Because the PCU design may be based on a specific patient population, assessment of the population to be served and the level of nursing vigilance that will be required must be a central focus when gathering resources for PCUs. Questions to answer include: How often and what types of vital signs need to be monitored? Will multiparameter monitoring, such as hemodynamics, oxygen saturations and ventilator weaning status, be needed? Will patients require frequent mobilization to other units or departments for procedures or tests? How many and what types of staff are needed?
For example, patients who have progressed to stable critical states may be considered capable of withstanding transport off the unit for scans, x-rays or procedures. Moving patients from department to department when equipment is not portable places a burden on PCU nurses and their efforts to maintain a consistent level of care. When a patient is moved, relevant data can be missed or misplaced, which increases the risk of medical errors, as well as the administrative time that may be necessary to manually transcribe information obtained during the patient’s transport. In addition, staff may be required to travel with the patient, taking them away from their patient assignments.
The Physical Environment
PCUs often have many structural constraints because, historically, they have been remodeling projects used to meet institutional specific needs for expansion. Thus, the PCU staff should be actively involved in providing insight into how the physical environment can best be arranged.
For example, construction should consider the rehabilitation aspect of patient care, while allowing for nursing vigilance. If units are not properly planned, they may be too small to provide the service that is required, or too large, creating the possibility that low-risk patients will be inappropriately admitted.2
Studies and systems analyses that estimate procedural times, travel times and emergency response times are important in assessing the physical layout of units and the patient care requirements. For example, does the unit layout allow for timely acquisition of critical information and access to patients? Planning the placement of emergency equipment, medications and documentation stations should take into account the safe proximity of the nurse to the patient and the equipment needed for surveillance. When the changing physical environment is extremely limited, technology may be the answer.
The Technology
When choosing technological resources, assess how they will enhance patient care. For example, PCU staff say that patient mobility and accessibility to patient information are two major causes of anxiety. Defining the level of mobility will help determine the type of monitoring devices chosen. Will patients require cardiac monitoring and emergency equipment during transport? Will patients be better served with telemetry or stationary monitoring capabilities?
Today, technological advances in telemetry systems allow nurses to monitor patients as they move around the hospital. These systems can transmit multiple data sets, such as heart rate, multilead ECG and pulse oximetry. This information can be viewed at the central nurses’ station. The systems can also be integrated into small, hand-held receivers, which can display a preview of the rhythm and alert the nurse to high-level alarms. Some telemetry systems allow for remote, centralized patient monitoring with rapid and secure nurse notification systems.
At the same time, computerization is changing the way healthcare is practiced and communicated. Some facilities have moved from paper-heavy charts to paperless, computerized documentation. Because patients in progressive care are in various stages of critical care recovery, timely access to information, including patient history and radiology and test results, is important.
Successful information systems enhancements in the PCU can also reduce unnecessary or redundant paperwork and administrative work. Integrating information systems allows PCU nurses to fully utilize patient data, which improves not only productivity and workflow at the point of care, but also patient outcomes. Nurses who have instant access to the information they need can make better-informed decisions about patients’ needs without leaving the point of care.
As hospitals move to networked environments, all patient care information from the ambulance to the hospital room is being linked to create a single data source. Collaboration among critical care units is imperative when making changes in how information and data flow. Hospital administrators, PCU clinicians, medical, and nursing leadership may want to consider forming a task force that explores both clinical concerns and administrative understanding of the facility’s strategic framework. For example, unilateral changes in monitors in one unit without the knowledge of the others may adversely impact standardization of staff training, supplies, biomedical support and data transfer into the electronic medical record.3
As patients move across the continuum of care, having a strong structure, competent staff, an easily accessible physical environment and technology that enhances workflow are becoming standard in the PCU. With adequate assessment and planning, this environment becomes an effective way to develop a quality outcome stay for patients on their way to recovery.
References
1. Berke WJ, Ecklund MM. Progressive Care Series, Part 1: Progressive care units continue to grow in numbers as the patient acuity gap between medical/surgical care narrows. Nurs Manage. 2002 Feb;32:26-29.
2. Keenan SP, Massel D, Inman KJ, Sibbald WJ. A systematic review of the cost-effectiveness of noncardiac transitional care units. Chest. 1998;113:173-177.
3. Halpern NA, Pastores SM. Technology introduction in critical care Just knowing the price is not enough! Chest. 1999;116:1092-1099.
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Grants
AACN offers a variety of small and large research grants. Jan. 15 is the deadline for three of these grants:
Philips Medical Systems-AACN Outcomes for Clinical Excellence Research Grant
This new grant, funded by Philips Medical Systems, will award $100,000 every three years to support studies that center on improved outcomes or system efficiencies in the care of acute or critically ill patients. Research conducted with this grant may apply to any age patient in any clinical environment, but must relate directly to at least one of AACN’s research priorities.
The grant will be awarded for the first time at AACN’s 2003 National Teaching Institute and Critical Care Exposition, May 17 through 22 in San Antonio, Texas.
Clinical Inquiry Grant
This grant supports multiple awards of $500 each, up to $5,000 annually, for clinical research projects that directly benefit patients or families. Interdisciplinary projects are especially invited.
AACN End-of-Life/Palliative Care Small Projects Grant
This award provides $500 each to two projects focusing on end-of-life or palliative care outcomes in critical care.
Other Grants
Feb. 1 is the deadline for several other grants:
Datex-Ohmeda-AACN Research Grant
Sponsored by Datex-Ohmeda, this grant provides up to $5,000 to support research by a critical care nurse addressing the issue of nutritional assessment in the critically ill patient.
AACN Critical Care Grant
This grant awards up to $15,000 to support research focused on one or more of AACN research priorities. The proposed research may not be used to meet the requirements of an academic degree.
AACN Mentorship Grant
The grant awards up to $10,000 to support research done by a novice researcher working under the direction of a mentor with expertise in the area of proposed investigation. The novice researcher will be the principal investigator and will receive the award. The novice researcher may be conducting the research to meet requirements for an academic degree, but the mentor may not. The mentor may not be a mentor on an AACN Mentorship Grant for two consecutive years.
AACN Certification Corporation Research Grant
Sponsored by AACN Certification Corporation, this grant awards up to four awards of $10,000 each for studies related to certified practice.
To find out more about AACN’s research priorities and grant opportunities, visit the AACN Web site at http://www.aacn.org > Clinical Practice > Research. The grants handbook is also available from AACN Fax-on-Demand at (800) 222-6329. Request Document #1013.
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Strengthening Practice: Research Work Group Builds on Success
Members of the 2003 Research Work Group are (from left,
seated) Susan Woods, Elaine Steinke and Sandra Smith and
(from left, standing) Mary Jo Grap, Shu-Fen Wung, Linda Henry,
Deborah B. Laughon and Justine Medina. Work group member Susan
Barnason is not pictured.
By Elaine E. Steinke, RN, PhD
Chair, Research Work Group
Meeting in Costa Mesa, Calif., in August, the 2003 Research Work Group laid out an agenda for an exciting and busy year of research activities.
The group has formulated ideas on how to enhance and further promote the grants programs, and to identify resources to strengthen both research and evidence-based practice. In addition, the Distinguished Research Lecturer Award criteria and application process will be further refined.
The group will also build on the successful research activities at last year’s National Teaching Institute to develop a variety of research, research application and evidence-based practice sessions for NTI 2003, May 17 through 22 in San Antonio, Texas.
Other members of the Research Work Group are Susan Barnason, RN, PhD, CCRN, CS, Mary Jo Grap, RN, PhD, ACNP, Linda Henry, RN, MS, Sandra Smith, RN, PhD, APRN, Susan Woods, RN, PhD, and Shu-Fen Wung, RN, PhD. Deborah B. Laughon, RN, BSN, MS, DBA, CCRN, is the AACN board liaison and Practice Director Justine Medina, RN, MSN, is the staff liaison.
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Research Corner: Myth Versus Reality Follow Guidelines When Measuring Blood Pressure
By Fred J. Jowdy, RN, MN
Scenario: A patient is admitted to the cardiac care unit from the emergency department and is able to slowly walk from the stretcher to the bed. Impatiently, the physician requests a blood pressure measurement. The nurse, unable to locate an automatic cuff, grabs a manual cuff that barely fits around the patient’s arm, rapidly inflates it to 200 mm/Hg and then rapidly deflates it while attempting to hear the sounds of Korotkoff.
Myth: Taking a manual blood pressure is easy and involves only a small potential for error.
Reality: Clinicians often fail to follow suggested blood pressure measurement guidelines. The problem is compounded by the fact that the BP equipment used is often inaccurate. Experts suggest that consistent underestimation of diastolic pressure could reduce the number of patients accurately identified as hypertensive by as much as 62%.1
Many factors affect the systemic arterial pressure and its measurement. Among these are the type of stethoscope head used, patient respiration, clinician bias, arm circumference, arm position, interaction between patient and clinician, and a phenomenon known as “white coat hypertension.”2
Stethoscope Head
Studies have reported higher systolic values and lower diastolic values when the bell instead of the diaphragm of the stethoscope is used.3,4 Because sounds generated within the vessel are of relatively low frequencies, the bell should be used to measure BP. The bell should be applied firmly, but with as little pressure as possible and with no space between the patient’s skin and the instrument.
Patient Respiration
Early studies showed that a patient’s respiration could negatively affect BP. The inspiratory portion of respiration normally results in a small decrease in systolic arterial pressure (<10 mm/Hg) as a result of the decrease in stroke volume.5
Clinician Bias
A British study performed on 2,596 male and female subjects demonstrated significant differences between clinicians while obtaining the systolic pressures of the subjects.6 Possible causes of clinician bias include:
• Systematically reading higher or lower than actual pressure.
• A tendency to round off to the nearest even number.
• Prejudice either for or against certain values.
• Differences in the way Korotkoff sounds were interpreted.
• How quickly the clinicians reacted to changes in Korotkoff sounds.7
Bladder Size and Arm Circumference
There has been extensive study about adequate BP cuff and bladder size. The width of the bladder should be 40% and the length 80% of the arm circumference. Care should be taken to place the center of the bladder directly over the brachial artery. (This placement is achieved by literally folding the bladder/cuff in half, not necessarily by locating markings of the manufacturer.)3 If the bladder is too wide, the pressure will be underestimated; if the bladder is too narrow, the pressure will be overestimated.
Arm Position
One study demonstrated that both the systolic and diastolic pressure were markedly lower when the arm was positioned in line with the right atria instead of resting on the arm of a chair at lower than the heart level.8 World Health Organization guidelines recommend that the cubital fossa be placed at the heart level as approximated by the fourth intercostal space,9 while the American Heart Association recommends that the midpoint of the upper arm be at the level of the heart.10 Conversely, if the arm is positioned above the level of the right atrium, BP readings can be falsely low and misleading.5
Gender Interaction
In a prospective study of 56 hospital outpatients, data revealed that, though blood pressure showed no marked interaction with clinician and patient sex, the difference between machine and age-adjusted clinical measurements for SBP was markedly greater in female patients when blood pressure was measured by male clinicians.11
White Coat Hypertension
White coat hypertension was first described in 1940 when it was noted that blood pressures taken in the clinic were markedly greater than blood pressures taken at home.12 It was generally thought that the patient’s anxiety over being seen by a clinician (in a white coat) accounted for the disparity. This is one of the primary reasons that home blood pressure monitoring has become so important in the accurate diagnosis of hypertension.
Recommendations
In 1993, the journal Circulation published the AHA’s recommendations for “Human Blood Pressure Determination by Sphygmomanometry.”10 Reprints of this article are available from the Office of Scientific Affairs, American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231-4596. An online version can be viewed at http://216.185.112.5/presenter.jhtml?identifier=3000894.
References
1. Campbell N, McKay D. Accurate blood pressure measurement: why does it matter? Can Med Assoc J. 1999;161:277-78.
2. Bailey R, Bauer J. A review of common errors in the indirect measurement of blood pressure. Arch Int Med. 1993;153:2741-2748.
3. Kirdendall W. Proper measurement of blood pressure. Hypertension. 1982;8:6-12.
4. Mauro A. Effects of bell versus diaphragm on indirect blood pressure measurement. Heart Lung. 1988;17:489-94.
5. Shabetai R, Fowler N, Gueron M. Effects of respiration on aortic pressure and flow. Am Heart J. 1963;65:525-533.
6. Bruce N, Cook D, Shaper A. Differences between observers in blood pressure measurement with an automatic oscillometric recorder. J Hypertens. 1990;8:S11-S13.
7. Bruce N, Shaper A, Walker M, Wannametheel G. Observer bias in blood pressure studies. J Hypertens. 1988;6.
8. Netea R, Lenders J, Smits P, Thien T. Arm position is important for blood pressure measurement. J Hum Hypertens. 1998;13:105-109.
9. WHO/ISH. 1993 Guidelines for the management of mild hypertension: memorandum from a WHO/ISH meeting. Hypertension. 1993;22:392-403.
10. Perloff D, Grim C, Flack J, Frohlich E, Hill M, McDonald M, Morgenstern B. Human blood pressure determination by sphygmomanometry. Circulation. 1993;88:2460-70.
11. Millar J, Accioly J. Measurement of blood pressure may be affected by an interaction between subject and observer based on gender. J Hum Hypertens. 1996;10:449-453.
12. Ayman D, Goldshine A. Blood pressure determinations by patients with essential hypertension: I. The difference between clinic and home readings before treatment. Am J Med Sci. 1940;200:465-4.
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Applications for 2004 Distinguished Research Lecture Award Due Dec. 1
Dec. 1 is the deadline to apply for the 2004 AACN Distinguished Research Lecture Award. The recipient will present the Distinguished Research Lecture at the NTI scheduled for May 15 through 20, 2004, in Orlando, Fla.
The Distinguished Research Lecture Award recipient receives a $1,000 honorarium and $1,000 toward NTI expenses.
For more information, contact Research Associate Dolores Curry at (800) 394-5995, ext. 377; e-mail, dolores.curry@aacn.org.
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Practice Resource Network
Q: We had a patient who was experiencing what the physicians thought was abdominal compartment syndrome. They asked us to do a bladder pressure measurement, but we really didn’t know how. We were unclear about what the pressure was supposed to be, if we were measuring the pressure correctly and if we were using the right kind of needle. Can you give us more information?
A: Abdominal compartment syndrome is the result of an acute increase in intra-abdominal pressure. This most commonly occurs in the multiple trauma patient, though patients with continued bleeding into the abdominal cavity, placement of intra-abdominal packs to control bleeding, significant intra-abdominal trauma and intra-abdominal hematomas are also at risk. In addition, use of military antishock trousers and abdominal packing during damage control surgery places the patient at high risk for ACS. Medical conditions such as cirrhosis with ascites, hemorrhagic pancreatitis, neoplasm and pregnancy are also risk factors for development of IAP and ACS.1,2
Signs and symptoms of ACS are tense abdominal distention, elevated ventilatory pressures, elevated central venous pressure and decreased cardiac output. Renal and neurologic function may also be compromised. Administration of fluid volume does not improve the clinical picture. Abdominal decompression by surgical intervention or paracentesis, depending on the underlying cause, is the treatment of choice for ACS.1
Direct pressure measurement can be done using a peritoneal dialysis catheter. Indirect measurement has been attempted through nasogastric tube, rectal tube and bladder pressure measurement. Bladder pressure measurement is generally accepted as the standard for measuring intra-abdominal pressures.2
Burch, et al,3 assigned a grading system of Grade 1-IV to the various levels of intra-abdominal pressure. Grade I is equivalent to 7-11mm Hg or 10-15 cmH2O and requires continued monitoring. Grade II is equivalent to 11-18 mm Hg or 15-25 cmH2O. The need for treatment of Grade II will depend on the patient’s clinical presentation. Grade III is equivalent to 18-26 mm Hg or 25-35 cmH2O, and the patient may exhibit signs and symptoms indicating the need for decompression. Grade IV is equivalent to >26 mm Hg or >35 cmH2O, and abdominal decompression is necessary.4
Normal bladder pressure will be 0 mm Hg, but may fluctuate from 0-15 mm Hg after abdominal surgery.2 Measurement of bladder pressures requires that there be less than 100 cc fluid volume in the bladder. At higher volumes the bladder wall starts to contract and exert additional pressure on the fluid. Patients should be lying supine with the manometer or transducer leveled to the symphysis pubis. Head elevation will cause increased pressure of abdominal contents on the bladder, however, if the patient cannot tolerate supine position, make note of the head elevation at baseline and continue measurement at that level for trend information. Measurements should be taken at end expiration.1
For step-by-step instructions on setup and measurement of intra-abdominal pressure by bladder pressure measurement, see the AACN Procedure Manual for Critical Care, 4th Ed.
References
1. Lozen Y. Intra-abdominal hypertension and abdominal compartment syndrome in trauma: pathophysiology and interventions. AACN Clin Issues. 1999;10:104-112.
2. Gallagher JJ. Intra-abdominal pressure monitoring. Lynn-McHale D, Carlson, K., eds. In: AACN Procedure Manual for Critical Care, 4th Ed. Philadelphia, Pa: W B Saunders; 2001.
3. Burch JM, Moore FA, Francoise R. The abdominal compartment syndrome. 1996:76:833-842.
4. Paiano R. Abdominal and genitorurinary trauma. In: Cohen S, ed. Trauma Nursing Secrets. S. Philadelphia, Pa. Hanley and Belfus. 2003.
Do you have a practice-related question? Call the Practice Resource Network at (800) 394-5995, ext. 217, or visit the AACN Web site at http://www..aacn.org > Clinical Practice > General Practice > PRN.
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AACN Clinical Pocket References Now Available for PDAs
AACN has released two pocket references for use on Palm OS PDA devices.
• The Cardiac Medications pocket reference provides information on common cardiac medications, including loading and maintenance dosages, indications and contraindications.
• The Laboratory Values pocket reference offers a wide range of laboratory results, including hematology, arterial blood gases, coagulation studies, immunology/serology, blood chemistry, drug levels, cerebrospinal fluid and urine chemistry, as well as a blood collection reference tool.
Hundreds of AACN members have already found the laminated version of these essential reference tools indispensable. Now, these electronic versions allow you to clear your pockets and look up critical information in seconds. The price is only $7.
To order these two new references, visit the AACN PDA Center (http://www.aacn.org > bookstore > AACN PDA Center > Specials > What’s New. Additional electronic pocket references are in development, so check back often.
Try the Tutorials
While visiting the AACN PDA Center, be sure to explore the tutorials that are designed to help nurses understand the utility and convenience of the PDA in nursing practice. Each tutorial contains actual screen images from PDA software applications and depicts detailed information on numerous clinical nursing software programs that will complement and enhance nurses’ efficiency in caring for patients at the bedside.
The first lesson, titled “Choosing a PDA for Nursing Practice,” presents helpful information on selecting the PDA that is right for you. “PDA Software for Clinical Nursing Practice” explores the abundance of nursing software programs specific to critical care and advanced nursing practice. “Griffith’s 5-Minute Clinical Consult and Davis’ Drug Guide for Nurses” takes you through a clinical scenario and demonstrates the comprehensive content contained in these two PDA applications.
CCRN Practice Exams
You can also purchase the CCRN adult, neonatal and pediatric CCRN Practice Exam Questions for the PDA. Designed for devices using Palm OS operating systems, these programs allow you to tailor your learning in a variety of ways. You may customize your test by selecting a specific category, such as cardiovascular, renal, pulmonary and synergy, or take the entire exam in either sequential or random order. Results are depicted as both percentage and number of correct answers, and sorted by clinical category, which gives you immediate feedback on your performance and areas for further study.
Each practice exam PDA software program is $22, and is immediately downloadable from the AACN PDA Center.
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