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Isgweb.aorn.orgSPECIAL NEEDS POPULATIONS
the Surgical Patient
KATHRYN PARRISH, RN, MSN
“silent disease” for many years because about 44 million Americans have been diagnosed until they develop great changes in bone strength Perhaps because of the increasing health care costs of treating osteoporosis, both health care the disease has become much more prevalent in the practitioners and patients are becoming more past 10 years, however, and the number of people aware of the disease. Many patients, because of diagnosed with the disease is increasing every year.
the often subtle nature of osteoporosis, may have Between 1995 and 2006, the hospitalization rate weak bones and not know the risk this poses to of patients being treated for osteoporosis-related their health. It is important for all health care hip, pelvic, and other fractures increased by 55% practitioners to be aware of this disease, to beaware of patients who exhibit osteoporosis risk according to a report from the Healthcare Cost factors, and to be prepared to care for them ap- and Utilization The authors of the report propriately. This article discusses how to care did not speculate as to why this percentage in- more effectively for surgical patients with creased so drastically. They did mention, how- ever, that, although osteoporosis is a preventable condition, it may not be detected and treated early WHAT IS OSTEOPOROSIS?
because of variations and limitations in insurance Osteoporosis is “an increased fragility of bone, coverage for early screening tests and that this which can lead to fractures,” according to Chris discrepancy will strain the US health care system Recknor, MD, medical director of the United as the population ages. Approximately $19 billion Osteoporosis Centers in Gainesville, Georgia (ver- was spent in 2005 for the treatment of osteoporo- bal communication, September 2009). In compari- sis-related fractures, and these costs are expected son, osteopenia is a condition that is characterized to rise to almost $25.3 billion by the year by bone mineral density that is lower than normal Women older than 50 years have a 50% chance but not low enough to be considered osteoporosis.
in their lifetime of sustaining a fracture related to Bone is composed of two types of bone tissue: compact (ie, cortical, lamellar) and trabecular (ie, patients 50 years of age and older will die within indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at The contact hours for this article expire June 30, 2013. bone tissue that makes up the outer shell of long Risk Factors
bones in the arms, legs, femoral neck of the hip, Osteoporosis affects both women and men of all wrist, and trabecular bone tissue is made up ages and ethnicities, but certain risk factors have of a meshwork of thin plates found in the center been identified as having an effect on the occur- of long bone and primarily makes up bone in rence of the disease. These risk factors include Throughout one’s lifetime, bone is constantly being degraded and rebuilt. Skeletal growth is a family history of osteoporosis or broken considered to be nearly complete between the ages of 18 and 20 years, and is considered fully resorption (ie, breakdown) and formation is called bone remodeling. During aging, the process of regrowth naturally slows and causes areas of bone In addition to aging, a person also may have other factors that cause the slowing of bone re- excessive vitamin A, protein, sodium, or caf- growth or interfere in some part of the bone re- modeling process and the quality of bone forma- tion, leading to weakening of bone and possible alcohol abuse or have more than three drinks certain medications, chronic illnesses, loss of es- taking certain medications (eg, steroids, someanticonvulsants, anticoagulants, barbiturates, Classes and Types of Osteoporosis
There are two classifications used when diag- certain chronic diseases and conditions (eg, nosing osteoporosis and its cause: primary and anorexia, rheumatoid arthritis, cystic fibrosis, secondary osteoporosis. Primary osteoporosis is gastrointestinal disorders, gastric bypass or the result of normal bodily processes and is further separated into type 1 and type 2. Type 1 Although these risk factors may increase the primary osteoporosis occurs in postmenopausal chance of new osteoporosis development, the dis- women after their estrogen levels have decreased ease should not be ruled out in those who do not significantly. Bone loss during the five to 10 exhibit risk factors. The National Osteoporosis years after menopause is the greatest in a wom- Foundation suggests that risk factors for osteopo- an’s lifetime. Type 2 primary osteoporosis is rosis be assessed in all men and postmenopausal associated with older age, occurs more slowly women over the age of 50 years, and, if risk fac- than type 1, and, typically, is not perceptible tors exist, then they should undergo bone mineral until age 75 years.Secondary osteoporosis is usually the result of a congenital or chronic disorder, surgery, the use of certain medica- Evaluation and Diagnosis
tions, or immobility.The class and type of The typical clinical patient workup for osteoporo- osteoporosis is determined by a full clinical sis consists of a health history and physical as- workup that assesses multiple factors.
sessment, BMD testing, spine radiographs to TABLE 1. T-Score and Z-Score Ranges1,2
* Ranges vary related to type of machine used and other factors. 1. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008. Accessed March 19, 2010.
2. O’Connell MB, Vondracek SF. Osteoporosis and other metabolic bone diseases. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM,eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: The McGraw-Hill Companies, Inc; 2008:1483-1498. confirm or rule out vertebral fracture, and certain which is important to assess when determining a laboratory tests. At times, urine and serum bio- person’s overall bone health and possible treat- markers may be measured to determine bone turn- ment because about 85% of vertebral compression sessment should focus on risk factors for At times, physicians may choose to be more osteoporosis, such as previous fractures; current aggressive in pharmaceutical treatment when a pain sites and pain scale rating; physical features patient has a T-score in the osteopenic range (ie, such as loss of height, enlarged abdominal girth, Ϫ1.0 to Ϫ2.4) and has one or more fragility frac- kyphosis, scoliosis, or lordosis; and protrusion tures. These radiographs can and should be re- and tenderness of vertebral processes.
peated yearly or along with each BMD test for all Bone mineral density testing is performed by patients undergoing treatment for low bone mass dual-energy x-ray absorbiometry (ie, DXA scan).
to monitor changes and to diagnose new or fur- Anatomical sites used in evaluation are the lum- ther deterioration early. Magnetic resonance imag- bar spine, bilateral or unilateral hips, the wrist, ing (MRI) and nuclear medicine bone scans have and sometimes the total body. A report of the been used to evaluate bone health as well. These DXA scan will show the actual bone density tests can aid in determining the age of the verte- bral fracture and its effect on surrounding nerve Typically, vertebral radiographs are taken of the cervical, thoracic, and lumbar regions of the A bone biopsy may be performed in certain spine. These radiographs are used to determine cases in which the cause of osteoporosis cannot whether a patient has developed changes in the be found in the traditional workup and the physi- shape and size of the vertebral bones. A certain cian needs more information on the patient’s bone degree of change in the shape or size of the verte- remodeling process. A bone biopsy is typically brae signifies a vertebral compression fracture, performed as outpatient surgery. The patient most TABLE 2. Current Pharmacologic Treatments for Osteoporosis1,2
Generic and brand names
Testoderm TTS®, Testim®, Testoderm®, Androgel® 1%, Striant®, Alendronate (Fosamax®), risedronate (Actonel®), PO/IV ibandronate (Boniva®), IV zoledronate (Reclast®), IV pamidronate (Aredia®) D3 (cholecalciferol), D2 (ergocalciferol), 1,25(OH)2 vitamin D (Rocaltrol®) 1. Osteoporosis: A Guide to Prevention and Treatment. Boston, MA: Harvard Health Publications; 2010.
2. O’Connell MB, Vondracek SF. Osteoporosis and other metabolic bone diseases. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM,eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: The McGraw-Hill Companies, Inc; 2008:1483-1498. Premarin and Prempro are registered trademarks of Wyeth Pharmaceuticals, Inc, Philadelphia, PA; Estrace and Actonel are registered trademarks ofWarner Chilcott, Rockaway, NJ; Evista is a registered trademark and Forteo is a trademark of Eli Lilly and Co, Indianapolis, IN; Testim is a registeredtrademark of Auxilium Pharmaceuticals, Inc, Malvern, PA; Testoderm and Testoderm TTS are registered trademarks of ALZA Corp, Palo Alto, CA;Androgel is a registered trademark of Abbott Laboratories (formerly Solvay Pharmaceuticals), Abbott Park, IL; Striant is a registered trademark ofColumbia Laboratories, Inc, Livingston, NJ; Miacalcin is a registered trademark of Novartis Pharma Stein AG, Stein, Switzerland; Fosamax is a registeredtrademark of Merck & Co, Inc, Whitehouse Station, NJ; Boniva and Rocaltrol are registered trademarks of Roche Therapeutics, Inc, Nutley, NJ; Reclastand Aredia are registered trademarks of Novartis Pharmaceuticals Corp, East Hanover, NJ. often receives two rounds of tetracycline dosing Nonpharmacologic interventions for osteoporo- cycles before the biopsy as a way to “mark” the sis may include exercise; physical or occupational sample for proper visualization of bone mineral- therapy; and passive or active orthoses, which help with vertebral body alignment, pain reduc- taken from the iliac crest of the pelvis and is sent tion, muscle strength, and awareness of body po- to a laboratory for information on histomorphol- sition. Diet (eg, limiting caffeine, alcohol, carbon- ated beverages) and smoking cessation also helpin attaining peak bone mass and lowering the rate Current Treatment
After a diagnosis of osteoporosis has been made,the health care practitioner then can determine thecourse of treatment for that specific patient. Fac- THE SURGICAL PATIENT
tors that may affect this treatment include history There are many factors that should be considered of esophageal problems; digestive issues; inability when caring for the surgical patient with osteopo- to sit or stand for 30 minutes to one hour; fi- rosis. Surgical patients with concomitant illnesses nances and insurance coverage; transportation; or diseases may require a surgical team with more and resources, such as a medical facility with the specialized knowledge and expertise than surgical capability to perform outpatient infusions. There patients who are considered to be uncomplicated.
are several pharmaceutical options for treating Surgical patients with osteoporosis can be classi- fied in one of three ways: those having a surgical TABLE 3. Perioperative Considerations for the Patient with Osteoporosis
Ensure that the diagnosis of osteopenia or osteoporosis is indicated on the patient’s medical history and the surgeon is Discontinue any of the patient’s osteoporosis medications that will cause medical conditions or adverse effects during surgery (eg, esophagitis caused by lying flat or reclined for a period of time).
Assess fall risk at the preoperative assessment and on the day of surgery.
Closely monitor patients who are at a high risk of falling, especially when the risk increases (eg, because of preoperative Intraoperative care
Ensure that the entire surgical team is aware of the patient’s diagnosis of osteopenia or osteoporosis to ensure that special precautions are taken as needed to reduce the patient’s risk of injury.
Position the patient carefully to eliminate the risk of fracture, falling, or other trauma.
During positioning, pay special attention to bony prominences and add extra padding when appropriate.
If cardiopulmonary resuscitation becomes necessary, then the resuscitation team should attempt to prevent injury related to fractured ribs, sternum, or other bones.
Be prepared to take special precautions as necessary to decrease the risk of fracture or other injury if the surgeon diagnoses the osteoporosis during the surgery.
Document the patient’s diagnosis in preparation for postoperative discussions when a patient is diagnosed with Postoperative care
Maintain the treatments that were planned during the preoperative period to minimize the risk of complications.
Discuss rehabilitation options to help decrease postoperative pain and prevent a negative surgical outcome with the patient Inform the patient of potential adverse effects of postoperative medications (eg, steroids, chemotherapy medications, pain medications) so that he or she can receive proper follow-up to monitor for additional bone loss.
Notify the patient’s primary physician of the diagnosis if a diagnosis of osteoporosis is made during surgery.
Discuss with the patient the effect that a diagnosis of osteoporosis will have on his or her recovery (eg, requiring additional medications, specialized or lengthened rehabilitation) if a diagnosis is made during surgery.
procedure related to osteoporosis, such as a ky- a patient’s risk of having low bone mass will aid phoplasty, vertebroplasty, or bone biopsy; those in a thorough preoperative assessment. A compre- having surgery to repair a fracture or injury re- hensive assessment includes the surgical patients’ lated to osteoporosis; and those undergoing gen- concomitant diseases and medication history and eral surgery who have or have not been diagnosed may identify those who have a higher risk of in- previously with osteoporosis. Whichever category the surgical patient fits into, osteoporosis poses an The Joint Commission has identified reduction increased risk throughout the operative period, of injury related to falls as one of the National and certain factors should be considered when Patient Safety Fall risk should be deter- mined for all surgical patients at the preoperative Preoperative Considerations
assessment and on the day of surgery. Patients at Patients who have been previously diagnosed with a high risk of falling should be monitored closely osteopenia or osteoporosis should add this to their throughout the perioperative period, and precau- medical history and report this to the nurse and/or tions should be taken when the risk of falling in- surgeon during the preoperative history and physi- creases, such as after preoperative sedatives are cal examination. Awareness on the nurse’s part of The prescribing practitioner should discuss issues patient’s history of bone loss or osteoporosis so related to the patient’s osteoporosis treatment if the the team can take special precautions as needed.
patient must undergo a surgical intervention. The Special precautions might include more team general physician should be the one to discuss these members transferring the patient or use of differ- issues, but the surgeon also has a responsibility to ent transferring techniques or equipment. In some address any medication issues before surgery. The ORs, staff members are attempting to create a perioperative nurse should verify that the patient has “no-lift, no-transfer environment” to decrease the received appropriate and adequate preoperative teaching in preparation for surgery. Some medica- tions should be withheld before surgery and not re- have bone loss or to what extent their bones have started for a certain period of time afterward be- weakened. In some cases, the surgeon may iden- cause they can increase postoperative risks. Specific tify bone loss during surgery if the procedure re- reasons to hold medications include periods of im- quires working with bone tissue. This must be mobilization, limited mobility, and concomitant documented and discussed with the patient after medications or treatments that may interact with surgery so appropriate follow-up can occur, osteoporosis medications. For example, the risk of whether with the surgeon or with the patient’s esophagitis related to certain osteoporosis medica- primary physician. The perioperative nurse may tions increases when the patient must lie flat or even complete the documentation during the surgery, remain partially reclined for a period of time after but it is primarily the surgeon’s responsibility to document and address findings after the procedure.
Special precautions may need to be put into Intraoperative Considerations
place to decrease the risk of fracture or further Proper positioning of the patient with osteoporosis fracture of bone and possible hardware failure during surgery is important to eliminate the risk during the operative procedure. Bone loss needs of fracture, falling, or othertrauma. The entire surgicalteam should pay special at- Online Resources*
tention to bony prominences,and extra padding should be US Department of Health and Human Services to be taken into account by the surgeon when referring him or her to a primary care physician determining the most appropriate surgical course, or to a specialist for further evaluation and treat- and the surgeon holds the main responsibility for ment. The perioperative nurse might not be in- making changes during surgery. The nurse may volved in this exchange but may be involved in need to assist the surgeon in determining the ap- documenting during the surgical procedure.
propriate steps to take and gather the appropriate Many surgical patients require rehabilitation equipment. Special precautions that may be indi- after their procedures. For patients with osteopo- cated include using alternate techniques to accom- rosis, it is critical for rehabilitation staff members plish the surgery; using alternate surgical instru- to know about the diagnosis so they do not injure Postoperative complications for patients with osteoporosis may include hardware failure or delayed healing. If the bone surrounding implanted hardware or the site of surgery is thin and the remodeling process has decreased, then the fracture or surgical site may never fully heal. These complications can be decreased or avoided with proper preoperative planning and cardiopulmonary resuscitation (CPR). If the need Again, the nurse would be involved with docu- for CPR arises during the operative period, the mentation and that ensure the patient has received resuscitation team should be made aware of an appropriate education. Dr Recknor emphasizes osteoporosis diagnosis so they can try to prevent that patients with osteoporosis should receive re- injury related to fractured ribs, sternum, or other habilitation appropriate for their surgery because bones that may be affected during CPR.
it may lead to “decreased postoperative pain andincreased use of the extremity affected.” He notes Postoperative Considerations
that patients with osteoporosis need rehabilitation, Postoperative complications for patients with os- but the rehabilitation plan may need to be altered teoporosis may include such issues as hardware to account for slower bone health or to prevent failure or delayed healing. If the bone surround- injury to the patient (verbal communication, ing implanted hardware or the site of surgery is thin and the remodeling process has decreased, Surgical patients may need to take new medi- then the fracture or surgical site may never fully cations after their procedure, including steroids or heal. These complications can be decreased or chemotherapy or pain medications that can them- avoided if proper preoperative planning has taken selves cause bone loss or increase existing bone place and if proper follow-up is maintained in the loss. The patient should be informed of this po- postoperative period regarding osteoporosis treat- tential adverse effect so he or she can receive ment, whether by the surgeon or by the patient’s appropriate follow-up to monitor for bone loss via primary physician. Proper follow-up includes re- porting to the patient the findings of osteoporosis The surgeon and the patient should discuss re- or weak bone, and discussing treatment options or starting the patient’s osteoporosis medications after a surgical procedure. Results of research National Committee for Quality Assurance, Pfizer, Inc;nd:81-85.
have shown that oral bisphosphonates taken when O’Connell MB, Vondracek SF. Osteoporosis and other the patient does not or cannot remain upright for metabolic bone diseases. In: DiPiro JT, Talbert RL, at least 30 minutes after administration may cause Yee GC, Matzke GR, Wells BG, Posey LM, eds.
Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: The McGraw-Hill Companies, Inc; and selective estrogen receptor modulators should Medical dictionary: osteoporosis. Harvard Health Publi- be held until the patient is able to ambulate be- These risks can be decreased if proper planning Osteoporosis: A Guide to Prevention and Treatment. occurs both before and after a surgical procedure.
Boston, MA: Harvard Health Publications; 2010.
In a case in which the surgeon discovers bone Clinician’s Guide to Prevention and Treatment ofOsteoporosis. Washington, DC: National Osteoporosis loss during the surgical procedure, the surgeon should discuss this diagnosis at the postoperative visit or the surgeon or nurse should pass along Masala S, Schillaci O, Massari F, et al. MRI and bone the diagnosis to the patient’s primary physician.
scan imaging in the preoperative evaluation of painfulvertebral fractures treated with vertebroplasty and ky- The patient who is diagnosed with osteoporosis phoplasty. In Vivo. 2005;19(6):1055-1060.
during surgery may require osteoporotic medica- Kann PH, Pfützner A, Delling G, Schulz G, Meyer S.
tions or specialized or lengthened rehabilitation Transiliac bone biopsy in osteoporosis: frequency, indi-cations, consequences and complications. An evaluation of 99 consecutive cases over a period of 14 years. ClinRheumatol. 2006;25(1):30-34.
National Patient Safety Goals. Accreditation Pro-gram: Hospital. The Joint Commission. As the US population ages and osteoporosis be- comes more prevalent, it will become more likely that perioperative nurses will see patients with Possible side effects—Fosamax and Fosamax D this condition. The OR team must be cognizant of the special needs of the patient with osteoporosis and be prepared to care for him or her appropri- Moran-Higgins ME. Perioperative concerns for the pa- ately. By taking special considerations for the tient with osteoporosis. Orthop Nurs. 1985;4(3):68.
Timmons L. Creating a no-lift, no-transfer environment patient with osteoporosis, the surgical team can in the OR. AORN J. 2009;89(4):733-736.
prevent injury in all patients who may be at risk Important safety information. Premarin.com. Accessed February 24, Important information about EVISTA. Evista.com.
Osteoporosis: the silent disease. Citracal. Russo A, Holmquist L, Elixhauser A. US hospitaliza-tions involving osteoporosis and injury, 2006 [Statisti- Kathryn Parrish, RN, MSN, is an assistant
cal Brief #76]. The Healthcare Cost and Utilization professor of nursing at North Georgia College and State University, Dahlonega, GA. Ms Fast facts on osteoporosis. National Osteoporosis Foun- Parrish has no declared affiliation that could be perceived as posing a potential conflict of Focus on enhancing care for older adults. In: Quality interest in the publication of this article. Profiles: The Leadership Series. Washington, DC: EXAMINATION
CONTINUING EDUCATION PROGRAM
the Surgical Patient
To educate perioperative nurses about caring for surgical patients with osteoporosis.
1. Identify factors that increase the risk of osteoporosis.
2. Identify methods for detecting impaired bone health and osteoporosis.
3. Discuss interventions used to treat patients with osteoporosis.
4. Describe intraoperative considerations to minimize the risk of injury to the patient
5. Identify postoperative complications that may occur in the patient with osteoporosis.
The Examination and Learner Evaluation are printed here for your convenience.
To receive continuing education credit, you must complete the Examination and
Learner Evaluation online at
4. protrusion and tenderness of vertebral
Factors that increase the risk of osteoporosis 1. being overweight or obese.
2. Caucasian, Asian, or Hispanic/Latino ethnicity.
3. excessive vitamin A, protein, sodium, or caf-
The percentage of vertebral compression fractures that are related to osteoporosis is about 4. female gender.
5. older age.
A ____________________ may be performed in certain cases when the cause of osteoporosis can-not be determined in the traditional workup and Health history and physical assessment items that the physician needs additional information on the focus on risk factors for osteoporosis include patient’s bone remodeling process.
1. current pain sites and pain scale rating.
2. physical features (eg, loss of height, enlarged
b. bone mineral density test.
abdominal girth, kyphosis, scoliosis, lordosis).
c. magnetic resonance imaging test.
3. previous fractures.
d. nuclear medicine bone scan.
Interventions that are used to treat osteoporosis If osteoporosis is diagnosed during surgery, then special precautions that may be indicated include 1. bed rest.
1. using alternate techniques to accomplish the
2. limiting caffeine or alcohol intake.
3. passive or active orthoses.
2. using alternate surgical instruments that are
4. pharmaceutical treatment.
less invasive or reduce the risk of injury to the 5. physical or occupational therapy.
3. not performing a specific procedure, surgery,
4. intraoperatively administering methotrexate to
minimize postoperative arthritic inflammation.
Surgical procedures that may be required for pa- 1. bone biopsy.
Postoperative complications for a patient with 3. arthrodesis.
1. delayed or incomplete healing of a fracture or
2. hardware failure.
3. hypermobility of the joints.
During surgery, considerations that can lower the 4. decubitus ulcer development as a result of re-
risk of injury to a patient who has been diag- nosed with osteoporosis or exhibits risk factors 1. incorporating extra padding when appropriate
10. Because of increased risk of blood clots, after
2. positioning the patient to eliminate the risk of
surgery, the patient should not resume taking cer- tain ____________________ until after he or she 3. using more team members during patient
4. altering transferring techniques or equipment.
b. estrogens and selective estrogen receptor 5. creating a “no-lift, no-transfer environment.”
The behavioral objectives and examination for this program were prepared by Kimberly Retzlaff, editor, with consultation from Rebecca Holm, RN, MSN, CNOR, clinical editor, and Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education.
Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of in- terest in the publication of this article.
CONTINUING EDUCATION PROGRAM
the Surgical Patient
Thisevaluationisusedtodeterminetheextent 9. Willyouchangeyourpracticeasaresultof
to which this continuing education program reading this article? (If yes, answer question met your learning needs. Rate the items as 9A. How will you change your practice? (Select all that
1. I will provide education to my team regarding
To what extent were the following objectives of this 2. I will work with management to change/
Identify factors that increase the risk of osteoporosis. Low 1. 2. 3. 4. 5. High 3. I will plan an informational meeting with phy-
Identify methods for detecting impaired bone sicians to seek their input and acceptance of 4. I will implement change and evaluate the ef-
Discuss interventions used to treat patients with fect of the change at regular intervals until the change is incorporated as best practice.
Describe intraoperative considerations to mini- 5. Other:
mize the risk of injury to the patient withosteoporosis. Low 1. 2. 3. 4. 5. High 9B. If you will not change your practice as a result of
Identify postoperative complications that may reading this article, why? (Select all that apply) occur in the patient with osteoporosis.
1. The content of the article is not relevant to my
2. I do not have enough time to teach others
about the purpose of the needed change.
To what extent did this article increase your 3. I do not have management support to make a
To what extent were your individual objectivesmet? Our accrediting body requires that we verify the Will you be able to use the information from this time you needed to complete the 1.8 continuing education contact hour (108-minute) program: This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Centerapproves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of thisactivity for relicensure.
Event: #10049; Session: #4013 Fee: Members $9, Nonmembers $18
The deadline for this program is June 30, 2013.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Eachapplicant who successfully completes this program can immediately print a certificate of completion.
Ifrc - chernobyl humanitarian assistance and rehabilitation programme charp in belarus ukraine and russia (appeal 01.60/2001)
CHERNOBYL: HUMANITARIAN ASSISTANCE AND REHABILITATION PROGRAMME (CHARP) IN BELARUS, UKRAINE AND RUSSIA (Appeal 01.60/2001) Click on programme title or figures to go to the text or budget In CHF Introduction Programme Context As a result of the explosion of the fourth unit of the Chernobyl nuclear plant on 26 April, 1986 tens of thousands of square kilometres of land rema