Metal coffee cans with long-burning candles. The following are the therapeutic nursing interventions for Hypothermia: 1. Vasodilation occurs as the patients core temperature increases leading to a decrease in BP. 13. Do not rub while you are warming up. Evaluate for the presence of frostbite, if the patient has had prolonged exposure to a cold environment.Severe hypothermia generates ice crystals to form inside cells. Assess the patients level of pain.Pain is part of the normal inflammatory process. Nursing Care Plan for common cold? - frostbitetreatment.top Depending on the severity of your symptoms, you may be told to go to an emergency room. 11. With help from the store clerk, he removes his frozen shoes and finds his feet as well as his hands are pale, waxy, and numb. ZQ!8 P_S)Mm. 7@TR8b c\epR32^X9. Black, dead skin and tissues (gangrene) in severe cases. Nurses can play a fundamental role in teaching both patients and members of the general community how to stay safe in the cold. Although the circumstances may differ, frostbite threatens people living, working, or traveling in cold climates. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Diagnosing frostbite is based on your signs and symptoms, skin appearance, and a review of recent activities in which you were exposed to cold. Moderate to severe hypothermia increases the risk for ventricular fibrillation, along with other dysrhythmias. 11. A warm bath or whirlpool for 20 to 45 minutes will help rewarm your limbs. Serous exudate from a wound is a normal part of inflammation and must be differentiated from pus or purulent discharge present in the infection. hb```e`` B@9Wf;F``l``Vu1``h7[ - Fu Q |[0e(zzSzofed#i>og;I]! Jewelry and other constrictive objects should be removed. Patients with who experience vomiting can easily become dehydrated and experience abdominal pain. He's wearing a business suit, trench-style raincoat, and no gloves. If a thermometer isn't available, use water that's the temperature of a hot tub; to test it, you as the nurse should be able to hold your hand in it for at least 30 seconds without feeling uncomfortable before immersing the patient's body part.3 If hot water must be added to maintain the target temperature, remove the patient's body part from the water until the water temperature is retested to ensure it isn't too hot before reimmersion.2 Prevent the patient's injured extremity from resting on the bottom or touching the sides of the water bath vessel to avoid inadvertent tissue trauma from pressure while the extremity is numb.2,8, Frostbite of the ears and nose can be managed by continually applying warm, moist compresses to the affected areas until thawing occurs.9. If you have time before your appointment, use the information below to get ready for your medical evaluation. Advertising revenue supports our not-for-profit mission. When tissue integrity is left untreated, it could cause local or systemic infection and ultimately lead to necrosis. 15. Soak for 20 to 30 minutes or until the skin becomes its normal color or loses its numbness. https://www.cdc.gov/disasters/winter/staysafe/frostbite.html. Because true tissue freezing doesn't occur, frostnip isn't typically included in the spectrum of frostbite injuries. t")1s=ic7N:9Ik&>o7k1 >83MC8. Explain all procedures and treatments to the patient and SO.Repeated explanations are needed to avoid confusion. HVn@}G"^,U}hV jCz (2014). After tissues have thawed, the more viable body parts can have erythema, edema, and blisters.1 If the affected areas remain dark and dusky, fail to form blisters, and develop a hard, black eschar, then tissue necrosis, gangrene, or mummification may ultimately result, requiring eventual amputation.1 An accurate prognosis about tissue viability may not be possible for several weeks or months while the freezing injury fully evolves.1, In all degrees of frostbite, pain may be extreme during and after thawing, and it can last days to months depending on the amount of tissue lost.1 Pressure from clothing or shoes as well as activity can worsen the pain; manifestations such as tingling and sensations of electric shock and burning have also been reported.2 Various intensities of sensory loss occur in the affected part for all degrees of frostbite and generally persist from 4 years to indefinitely.1, Because virtually all frostbitten body parts look similar while they're still frozen, the extent of damage can't be reliably determined until the body part thaws and the wounds evolve over time to reveal the line of demarcation between viable and necrotic tissue.1,4 This period can extend from 45 days to 3 months after the cold injury.1,3. Assessment is required to recognize possible problems that may have lead to Impaired Tissue Integrity and identify any episode that may transpire during nursing care. A new proposal for management of severe frostbite in the austere environment. In the event of extreme conditions, seek shelter as soon as possible. British Journal of Sports Medicine. The treatment for this child during the first 48 hours will be most likely be related to: hypovolemic shock. 14. Give extra covering (passive warming), such as clothing and blankets; cover postoperative patients with heat-retaining blankets.Warm blankets provide a passive method for rewarming. Systematic inspection can identify impending problems early and provide early treatment. S Sterile dressings should be used to wrap the affected part if immediate medical help is available before rushing the patient to the emergency department for further care. 10. Yes, Recommendations based on patient-oriented outcomes? - May discharge when wound care plan established and patient on oral pain medication. Rapid rewarming via water bath immersion and intravenous low-molecular-weight dextran leads to improved outcomes in frostbite. Assess patients nutritional status; refer for a nutritional consultation or institute dietary supplements.Inadequate nutritional intake places the patient at risk for skin breakdown and compromises healing, causing impaired tissue integrity. Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite. See permissionsforcopyrightquestions and/or permission requests. Addressing hypothermia is the first priority, followed by evacuation to definitive care in a hospital that can provide the advanced monitoring, diagnostic studies, and interventions needed. In cases where the feet are involved, bed cradles may be used to prevent contact with bedclothes. Interprofessional patient problems focus familiarizes you with how to speak to patients. Creating Nursing Care Plans: The Definitive Guide - Simple Nursing 9. Hypothermia: First aid - Mayo Clinic O Observe the patient for signs of hypothermia or lowered body temperature and manage the condition accordingly. endstream endobj 281 0 obj <>/Metadata 19 0 R/Outlines 49 0 R/Pages 278 0 R/StructTreeRoot 54 0 R/Type/Catalog>> endobj 282 0 obj <>/MediaBox[0 0 612 792]/Parent 278 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 283 0 obj <>stream Handford C, Buxton P, Russell K, et al. Early rewarming of the tissue appears to decrease injury or damage. Management of moderate-to-severe hypothermia takes priority over management of frostbite. American Academy of Pediatrics; 2019. To aid the warming process, the water should be kept circulating. 15 November, 2005. Take all medications antibiotics or pain medicine as prescribed by your doctor. This involves consideration of the central theories of nursing and discussion of nursing models and the nursing process. Wolters Kluwer Health First-degree frostbite causes numbness, erythema, and often edema. Nursing Interventions and Outcomes for the Diagnosis of Impaired Tissue Integrity in Patients After Cardiac Catheterization: Survey. In the best possible case, this traveler's treatment in the local ED would include removal of his wet clothing; the application of warm, dry blankets around his body; and immersion of his feet and hands in water baths at temperatures of 37 C to 39 C (98.6 F to 102.2 F) for at least 30 minutes. Left untreated, it can be life-threatening. 280 0 obj <> endobj Alarmed, he asks the clerk to call an ambulance. Air dry after the bath. This content is owned by the AAFP. Frostbite. Frostbite is a cold-related injury characterized by the freezing of tissue. The flush would indicate that the circulatory flow is re-established. For the face or ears, apply a warm, wet washcloth. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. If possible, thawed extremities should be elevated above the heart to decrease edema. 299 0 obj <>/Filter/FlateDecode/ID[<8077CADA29399A4E9C452830676D15DB>]/Index[280 53]/Info 279 0 R/Length 101/Prev 466515/Root 281 0 R/Size 333/Type/XRef/W[1 3 1]>>stream your express consent. Accessed July 13, 2018. A sterile gauze or cotton should be placed between the fingers or toes of affected extremity. Applying aloe vera cream or gel inhibits thromboxane and may promote wound healing.1,3,9, Expect significant edema to develop after frostbitten areas have been thawed. All rights reserved. Evidence on outcomes is lacking, but hydrotherapy has few negative sequelae and may benefit recovery. The toes and fingers, as well as the arms and legs, are frequently impacted by gangrene. Telemedicine, including virtual Internet-based consultation, is being used in many areas to obtain expert assistance with patient management. Massage should never be done in this case. If ordered, turn and position the patient at least every two (2) hours and carefully transfer the patient.This is to avoid the adverse effects of external mechanical forces (pressure, friction, and shear). iloprost, a prostacyclin analog, demonstrated significant efficacy in long-term tissue salvage when administered for severe frostbite in a European study when compared with other methods. This content does not have an Arabic version. They used angiography to identify perfusion deficits with subsequent catheter-directed infusion of intra-arterial fibrinolytic agents in 66 patients found to have arterial thrombosis.11 Outcome data from 62 patients included in the analysis revealed a complete digit salvage rate of 68.6%. For more information, check out our privacy policy. Frostbite: Recommendations for Prevention and Treatment from the - AAFP Rewarming fist aid may be given in cases where immediate care is unavailable. The depth of tissue freezing determines the degree of frostbite injury and associated signs and symptoms. Consider using electric or chemical warmers or hot packs to increase warmth. In: 9. Kelly AP, et al. Other recommended site resources for this nursing care plan: Recommended resources for the nursing diagnosis impaired tissue integrity and care plan: document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Gil Wayne ignites the minds of future nurses through his work as a part-time nurse instructor, writer, and contributor for Nurseslabs, striving to inspire the next generation to reach their full potential and elevate the nursing profession. Drink warm liquids. Impaired skin integrity related to frostbite as evidenced by open skin lesions GOAL With 2-3 days of nursing intervention, the patient will be able to: -Discussany altered sensation or pain at the site of tissue. Are tests needed to confirm the diagnosis? Exposure of the skin to temperatures below the freezing point this condition develops abnormally. The late ischemic phase involves progressive tissue ischemia and infarction from a cascade of events: inflammation, intermittent vasoconstriction, reperfusion injury, emboli in microvessels, and thrombus formation in larger vessels. The patient may start to remove clothing and bed covers. All Rights Reserved. Tissue plasminogen activator improves outcomes for deep frostbite extending to proximal interphalangeal joints if given within 24 hours. 8. The tissue may be blackened and die resulting to gangrene. Moisture promotes evaporative heat loss. Also avoid contact with liquids such as gasoline or alcohol that remain in a liquid state at subfreezing temperatures. Frostbite is not an inherently infection-prone injury, so antibiotic prophylaxis is unnecessary. Accessed July 13, 2018. 2016. For all other frostbite, after appropriate first aid and assessment for hypothermia, medical treatment may involve rewarming, medications, wound care, surgery and various therapies, depending on the severity of the injury. Instruct patient, significant others, and family in the proper care of the wound, including handwashing, wound cleansing, dressing changes, and application of topical medications).Accurate information increases the patients ability to manage therapy independently and reduces the risk for infection. However, frostnip can be a precursor to permanent tissue injury if immediate measures aren't taken to prevent tissue freezing.4 A body part with frostnip is typically numb and appears frosted on the surface or blanched, but the overlying skin itself remains soft and pliable and isn't frozen.2. Assess the patients readiness to reach a toileting facility, both independently and with assistance.This allows the nurse to plan for assistance. The following measures can minimize the risk of frostbite: Protecting skin from moisture, wind, and exposure to cold, Increasing insulation and skin protection (e.g., adding layers of clothing, wearing mitts instead of gloves), Using supplemental oxygen in extremely hypoxic conditions (above 25,000 ft [7,500 m]), Avoiding alcohol, illicit drugs, or medications that reduce perfusion, Avoiding cold weather exposure during illness, Using chemical or electric hand and foot warmers, Avoiding the use of skin emollients, which do not protect against frostbite and may actually increase risk, Maintaining adequate hydration and nutrition, Minimizing blood flow constriction caused by tight clothing or footwear, Frequently assessing for extremity numbness or pain and warming extremities as soon as possible if there is concern that frostbite is developing, Recognizing frostnip or superficial frostbite before it becomes more serious. VOL: 101, ISSUE: 46, PAGE NO: 52 Angela Davies, BSc, RGN, DipHE, is clinical nurse specialist - tissue viability, Pennine Acute NHS Trust, North Manchester General Hospital . Rapid warming can induce ventricular fibrillation. And you can get these blisters on your hands. Frostbite. For very severe cases, blisters may occur. All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health, Nursing Care Plans (NCP): Ultimate Guide and Database, Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing, 11 Nursing Appreciation Quotes from World Leaders, 6 Guillain-Barre Syndrome Nursing Care Plans. All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental HealthIncludes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. The scenario described in the beginning of this article is one example of the risk inherent in cold weather. Oral fluids can be given to alert patients; otherwise, intravenous saline (ideally warmed to 104 to 107.6F [40 to 42C]) should be administered to maintain urine output. What kind of follow-up, if any, should I expect? The worst cases, the tissue can die, and you may need surgery to remove it. What are my treatment options and the pros and cons for each? A pilot study of the diagnosis and treatment of impaired skin integrity: dry skin in older persons. Assess the patient for evidence of hypothermia, illness, and injury. Check every two (2) hours for proper placement of footboards, restraints, traction, casts, or other devices, and assess skin and tissue integrity.Mechanical damage to skin and tissues (pressure, friction, or shear) is often associated with external devices. We may earn a small commission from your purchase. Encourage a diet that meets nutritional needs.A high-protein, high-calorie diet may be needed to promote healing. Gangrene Nursing Diagnosis & Care Plan. Blebs develop an hour to few days after the process of rewarming. The nurse is caring for a child with a severe burn. Malaquias, S. G., Bachion, M. M., Martins, M. A., Nunes, C. A. D. B., Torres, G. D. V., & Pereira, L. V. (2014). If possible, an ibuprofen regimen should be initiated in the field setting. Don't walk on frostbitten feet, if possible. The first degree is the least severe and has the best prognosis, and the fourth degree is the most severe and has the worst prognosis. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels. Substantial edema should be anticipated. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented. Developing nursing care plans - PubMed Normal body temperature is around 37 C (98.6 F). 20. Frostbite prevention is a major component of military and wilderness planning. In below-freezing temperatures, avoid touching metal with bare hands. Premedicate for dressing changes as necessary.Manipulation of deep or extensive cuts or injuries may be painful. 9. 8. The article references the current version of this guideline. Unfractionated or low-molecular-weight heparin is commonly used with tPA, and case reports document use with iloprost, but there is no evidence for the use of heparin as monotherapy. Your message has been successfully sent to your colleague. The following descriptions provide an overview of frostbite injury progression. 1,2 Unfortunately, many of these risk factors are seen together in emergency department patients. Monitor the status of the skin around the wound. ears. The development of the plan is a stage in the nursing process. Ensure proper nutrition and stay hydrated. "It can be red. For example, use of I.V. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, for video Mayo Clinic Minute: Why the risk of frostbite is greater than you think, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Mayo Clinic Minute: Why the risk of frostbite is greater than you think, Mayo Clinic Minute: Don't get bit by frostbite, Expert Alert: Don't let common winter injuries take you down. Nursing Assessment for Ineffective Cerebral Tissue Perfusion Assess the patient's mental status. In: Auerbach PS, Cushing TA, Harris NS, eds. Classify pressure ulcers by assessing the extent of tissue damage.According to the National Pressure Ulcer Advisory Panel, wound assessment is more reliable when classified in such a manner. Administer an analgesic for pain per doctors prescription. When frostbitten areas have been thawed in the field or prehospital setting, don't let the patient bear weight or otherwise use the involved body part to minimize the chance of further injury.2 Monitor for the development of compartment syndrome in rewarmed extremities and anticipate the need for urgent surgical evaluation and fasciotomy if compartment pressures are elevated.1 (See Signs and symptoms of acute compartment syndrome.) 5. Eat and dress to maintain adequate core body temperature. Ice crystals . Because the cutaneous circulation plays a primary role in thermoregulation and the subsequent development of frostbite, the most vulnerable areas of the body are those with the most variable blood flow. Yes, its the integumentary system. Nursing a patient with frostbite | Nursing Times B Be sure to conduct a physical assessment to observe for concomitant injury such as: I In dressing frostbite injuries, it is essential to use strict aseptic technique. Seek emergency medical care. Accessed June 30, 2014. Frostbite is a trauma where exposure to freezing temperatures and actual freezing of the tissue fluids in the cell and intercellular spaces takes place. In the freeze-thaw phase, ice crystals form intracellularly during rapid-onset freezing or extracellularly during a slower freeze. Administer oxygen as indicated.Providing oxygenation to patients with hypothermia can help to maintain adequate oxygen levels in the blood, avoid further complications, and support the bodys overall function during the hypothermic state. 10. Maintain the head of the bed at the lowest degree of elevation possible.To reduce shear and friction. The dressing replaces the protective function of the injured tissue during the healing process. -xBhP De#` [)J F - For injuries in the lower extremities, do not allow the patient to walk. Mayo Clinic does not endorse companies or products. This is done to prevent maceration. General Nursing Care Plans, Nursing Care Plans 4 Total Parenteral Nutrition (TPN Feeding) Nursing Care Plans The major goals for the patient undergoing total parental nutrition may include improvement of nutritional status, maintaining fluid balance, and absence of complications. Pain (severe, on passive motion, pressure, or stretch), Poikilothermia (skin that takes on the temperature of the environment). Some error has occurred while processing your request. Frostbite. Educate the patient on the need to notify the physician or nurse.This is to prevent further impaired tissue integrity complications. His frostbite would likely turn out to be superficial (first or second degree). 'Nm3wsRS4D3;^1;;7 To care for your skin after frostbite: Take all medications antibiotics or pain medicine as prescribed by your doctor. She and Lawrence J. Jones are directors of the Appalachian Center for Wilderness Medicine in Morganton, N.C., and members of the Blue Mountain Ski Patrol in Palmerton, Pa. 7 In recent years, the majority of frostbite cases have occurred in urban settings, where social disadvantage . Any changes in LOC, orientation, GCS score, or other neurological monitoring methods might indicate a decreased cerebral perfusion. 7. Other well-known contributing factors include wind chill, exposed skin, wetness, peripheral vascular disease or other causes of circulatory impairment, fatigue, substance misuse or abuse, altered consciousness or judgment, inadequate clothing or shelter, dehydration, smoking or nicotine use, immobility, and prior frostbite injury.1. 3. After several unsuccessful attempts to dig out his car with ungloved hands, he tries to call a tow truck but can't get a cell phone signal. To prevent worsening tissue damage, a frostbitten extremity should be rewarmed only if there is no risk of refreezing. When the body temperature drops, the heart, nervous system, and other organs cant work normally leading to complete failure of the heart and respiratory system and eventually to death. Monitor the patient's vital signs. Know signs of itching and scratching.The patient who scratches the skin to alleviate extreme itching may open skin lesions and increase the risk for infection. Remove wet clothes once you're indoors. Allow blisters to break on their own. Symptoms include cold skin and a prickling feeling, followed by numbness and inflamed or discolored skin. Impaired Tissue Integrity & Wound Care Nursing Care Plan, Nursing Assessment and Rationales for Impaired Tissue Integrity, Nursing Interventions and Rationales for Impaired Tissue Integrity, All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health, Nursing Care Plans (NCP): Ultimate Guide and Database, Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing, Wound care nursing: professional issues and opportunities. This surgical emergency can be caused by reperfusion of ischemic tissue. Briggs JK. AskMayoExpert. .3yQeYFpBLyTj.HTt/G'&Q}Xi)K{@C+u\bnX`*!]qU lyC For superficial frostbite that has been rewarmed, some people find it soothing to apply aloe vera gel or lotion to the affected area several times a day. (See Tips for preventing frostbite.). "[Those most at risk are] certain patients with diabetes, patients who have previous history of frostbite are prone to it, the elderly or your very young children, and also, for example, if you're dehydrated," he says. endstream endobj 288 0 obj <>stream Slipping and falling frequently on the snow-covered road, he reaches the store more than an hour later and pulls the door open with difficulty. The water temperature should be 96.8F to 104F (37C to 40C). Covering the face, ears, hands, and feet and other exposed areas is critical. Which is the most beneficial nursing intervention for this client? It directs the continuing provision of nursing care and aids in its evaluation. The effect of hydration on frostbite outcomes has not been studied, but appropriate hydration is important for recovery. Show Me RN-to-BSN Programs Types of Nursing Care Plans 2012;46:770. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. Four degrees of frostbite are classically described. Assess the site of impaired tissue integrity and its condition.Redness, swelling, pain, burning, and itching are indications of inflammation and the bodys immune system response to localized tissue trauma or impaired tissue integrity. If the windchill drops below negative 15 degrees Fahrenheit, not unheard of in the northern half of the U.S., frostbite can set in within half an hour. In: Taylor and Kelly's Dermatology for Skin of Color. Once the patient reaches a hospital or high-level field clinic, frozen tissue should be assessed to determine whether spontaneous thawing has occurred. McGraw-Hill Education; 2016. https://accessmedicine.mhmedical.com. Further rewarming is not beneficial if tissue has completely thawed. Wearing layered, properly fitting clothing that's windproof and waterproof to minimize wind chill is the best way to stay warm and dry. Pezzi, M. V., RabeloSilva, E. R., Paganin, A., & de Souza, E. N. (2016). Blood pressure within the normal range promotes adequate cerebral perfusion. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. Third-degree frostbite causes deeper hemorrhagic blisters, indicating that the injury has extended into the reticular dermis and beneath the dermal vascular plexus. Walls RM, et al., eds. Core warming is indicated when body temperature is below 30C (86 F). Nursing Care Plan, Diagnosis, Interventions Hypothermia, Low Body Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. 15. The most helpful diagnostic studies for this include arteriography, technetium-99m scintigraphy (bone scan), and magnetic resonance imaging.3,7,11, I.V. If the patient is incontinent, implement an incontinence management plan.Prevent exposure to chemicals in urine and stool that can strip or erode the skin. Keep a sterile dressing technique during wound care.A sterile technique reduces the risk of infection in impaired tissue integrity. 19. Frostbite poses risks to people living, working, playing, or traveling in cold climates. calf muscles. Nursing Care Plans Nursing Diagnosis & Intervention (10th Edition)Includes over two hundred care plans that reflect the most recent evidence-based guidelines. 7. endstream endobj 284 0 obj <>stream Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018. The prostacyclin analog iloprost (Ventavis) inhibits platelet aggregation, dilates blood vessels, downregulates lymphocyte adhesion to endothelial cells, and may have fibrinolytic activity. General Nursing Care Plans - Nurseslabs Although there is no evidence that adding antiseptic solution produces better outcomes, it is not likely to be harmful and may reduce infection risk. Nursing Diagnosis & Care Plan Guide for 2023 - Nurseslabs Laskowski-Jones, Linda MS, APRN, ACNS-BC, CEN, FAWM, FAAN; Jones, Lawrence J. BA, NREMT, FAWM.