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Pacers, ablation, cardioversion, telemetry, Intro to ACLS

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Title: Pacers, ablation, cardioversion, telemetry, Intro to ACLS


1
Pacers, ablation, cardioversion, telemetry, Intro
to ACLS
  • By Diana Blum
  • MCC
  • NURS 2140

2
  • A dysrhythmia is a disturbance of the rhythm of
    the heart caused by a problem in the conduction
    system.
  • Categorized by site of origin atrial , AV nodal,
    ventricular
  • Blocks are interruptions in impulse conduction
    1st, 2nd type 12, 3rd or complete heart block

3
To map to determine if regular or irregular
Each small box measures 0.04 1 big box (5 small
boxes) is equal to a HR of 300 2 big boxes is hr
of 150 3 big boxes is hr of 100 4 big boxes is hr
of 75 5 big boxes is hr of 60 6 big boxes is hr
of 50 7 big boxes is hr of 43 8 big boxes is hr
of 38
4
Large box estimate of heart rate works with
regular rhythms
5
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6
  • P-wave atrial electrical activity
  • QRS ventricular electrical activity
  • T wave resting phase of ventricle

7
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8
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9
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10
P wave
Measures 0.12-0.20
11
QRS WAVE
Measures 0.06-0.10
12
QT Wave
Measures approx 0.40-0.48 secs
13
Heart rates
  • NSR heart rate is 60-100bpm
  • ST heart rate 101-180 bpm
  • SB heart rate lt60 bpm

14
Calculating Heart Rate
  • Quick Estimate The 6-second Method
  • - count the of QRS complexes in a 6 sec.
  • length of strip multiply by 10
  • (the second mark is to 5 large boxes)
  • This can be used is rhythm is reg or unreg.

15
  • Count small boxes between two R waves. Divide
    into1500 Gives BPM

16
Atrial arrythmias
  • Normal sinus rhythm
  • Sinus tachycardia
  • Sinus bradycardia
  • Premature atrial contraction (PAC)
  • Supraventricular tachycardia
  • Atrial flutter
  • Atrial fibrillation

17
Ventricular arrythmias
  • Junctional rhythm
  • AV blocks
  • Premature junctional rhythm
  • Premature ventricular contraction (PVC)
  • Ventricular Tachycardia (V-tach)
  • Ventricular Fibrillation (V-Fib)
  • Torsade de Pointes (TdP)
  • Pulseless electrical activity (PEA)
  • Asystole

18
ARTIFACT
19
NSR
20
Sinus rhythm
  • PR interval- 0.12-0.20sec
  • QRS-0.06-0.10sec
  • QT segment 0.36-0.44 sec
  • Heart rate 60-100

21
Sinus arrhythmia
  • Hr 60-100 bpm
  • On strip it looks regular but does not map out
  • PR interval 0.12-0.20

22
Junctional escape rhythm
HR 40-60 bpm lt60 bpm is accelerated Rhythm is
regular Pwaves not always present
23
Junctional Rhythm
24
SB
25
Sinus Bradycardia
  • All criteria same except rate lt 60bpm
  • S/S dizziness, syncope, angina, hypotension,
    sweating, nausea, dyspnea
  • Sometimes no S/S
  • Treat underlying cause
  • IV atropine, pacemaker

26
Sinus BradycardiaYour pt is pale, c/o dizziness
fatigue. Pulse 56,BP 86/60
  • ACLS protocol
  • 1. airway
  • 2. oxygen
  • 3. ECG, BP, oximetry
  • 4. IV access
  • If s/s of poor perfusion altered mental status,
    CP,
  • hypotension, signs of shock
  • a. prepare for transcutaneous placing
  • b. atropine 0.5 mg IV while waiting
    for pacer
  • - may repeat for total 3 mg IV
  • c. epinephrine or dopamine drip while
    waiting pacer or
  • if pacing ineffective

27
ST
28
Sinus Tachycardia
  • All criteria same as with NSR except rate gt100
  • Causes fever, dehydration, hypovolemia,
    increased sympathetic nervous system stimulation,
    stress, exercise, AMI
  • S/S Palpations 1, angina and lt CO from lt V
    filling time
  • Treatment correct cause, eliminate caffeine,
    nicotine, alcohol. Beta blockers may be ordered

29
Sinus Tachycardia
  • Heart rate greater than 100 but less 180
  • Caused by external influences (fever, blood
  • loss, exercise)
  • Adenosine used
  • B-blockers may cause condition to worsen ( if MI
    limits vent function the heart will compensate by
    increasing rate then CO will fall)
  • Remember to identify and treat cause !!!

30
Supraventricular Tachycardia
31
Supraventricular Tachycardia
  • Impulse originates in AV junction or atria
  • Rhythm regular
  • A-fib most common cause
  • Ventricular rate 150-250
  • QRS normal configuration
  • Symptoms
  • palpitations, lightheadedness,
  • Loss of Conscious, CP, SOB

32
How to treat SVT
  • B-blockers ( to decrease conduction thru AV
  • node
  • Calcium channel blockers ( to decrease condux
  • thru AV node)
  • Radio frequency ablation

33
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34
SVT converted with Adenosinegiven rapid IV Push
stimulates vagal response. S/E
flushing,bronchospasm,AVblock
35
AV Blocks
  • First degree block
  • Second degree block Type I (Wenchebach)
  • Second degree block Type II (Mobitz II)
  • Third degree block
  • Bundle branch block

36
First degree heart block
Rate is usually WNL Rhythm is regular Pwaves are
normal in size and shape The PR interval is
prolonged (gt0.20 sec) but constant
37
1st degree block
  • AV node delays the impulse from the SA node for
    abnormal length of time
  • Causes
  • CAD, MI, drugs that act on AV node
    (digitalis)
  • Characteristics
  • PR interval gt0.20 seconds
  • Not serious but may progress to 2nd degree

38
1st degree block nursing intervention
  • Document the dysrhythmia
  • Monitor for progression to slower heart rate or
    worsening block
  • If progression noted, monitor pt, notify physician

39
Second degree heart block type 1
Pwaves are normal in size and shape Some pwaves
are not followed by QRS PR interval lengthens
with each cycle until it appears without QRS
Complex then the cycle starts over QRS is
usually narrow
40
2nd degree AV blockType I
  • AV node delays progression of SA node impulse for
    longer than normal
  • Some of the SA impulses never reach ventricles
  • P waves regular
  • Progressive lengthening of PR interval until one
    P wave is not conducted
  • CAUSE ischemia or injury to AV node

41
2nd degree Type I AV block
  • RISK often a temporary block after MI
  • May progress to complete(3rd degree)
  • block
  • TREATMENT freq. none needed
  • slow vent rate ATROPINE will
    increase AV conduction
  • To increase rate of SA
    nodeEPINEPHRINE

42
2ND degree nursing interventionsType I
  • Document
  • Monitor pt/vitals
  • If ventricular rate slows enough to produce
  • symptoms, document , notify physician

43
http//www.youtube.com/watch?vGVxJJ2DBPiQfeature
related
44
Second degree heart block type 2
Ventricular rate is usually slow Rhythm is
irregular Pwaves are normal in size and shape
(more pwaves than QRS) PR interval is within
normal limits QRS is usually wide
45
2nd degree Type II(Mobitz Type II)
  • Atrial rate 60 to 100
  • More P waves than QRS complexes
  • Ventricular response 21 or 31
  • No change in PR intervals of conducted P waves
  • CAUSES disease of AV node, AV junctional tissue,
    or His-Purkinje system, inferior MI

46
2nd degree Type II
  • RISK unpredictable may suddenly advance to
    complete hrt block
  • Especially common after inferior infarction
  • A DANGEROUS WARNING DYSRHYTHMIA
  • TREATMENT if vent rate slow, atropine or
    epinephrine
  • may need temporary pacer

47
2nd degree Type IINursing Interventions
  • Determine width of QRS
  • WATCH for widening QRS complex
  • width QRS indicates location in the conduction
    system of the block
  • - the wider the complex, the lower in
    the bundle branch system the block will be.
  • IF QRS WIDENS, NOTIFY PHYSICIAN IMMED.
  • Prepare for insertion of pacer
  • Assess vitals

48
3rd degree heart block of complete heart block
Ventricular rate is regular but there is no
correlation between pwaves and QRS Pwaves are
normal in size and shape No true PR interval
49
3rd degree block complete heart blockAV
dissociation
  • More atrial waves than ventricular
  • No conduction of atrial impulses
  • Atrial/ventricles beat independently
  • RISKS bradycardia which produces
  • a decrease in CO leading to hypotension
    myocardial ischemia
  • TREATMENT pacer
  • NURSING INTERVENTION monitor , hemodynamics ,
    prepare for pacer

50
Atrial Fibrillation
Erratic wavy base Pr is not measurable QRS 0.10
sec or less usually http//www.youtube.com/watch?v
VKxQgjj2yVUfeaturerelated
51
A fib continued
  • Atrial rate gt 400 bpm with a varying Ventricular
    rate
  • Overall rhythm irregular
  • No P waves, unable to measure PR interval
  • QRSnormal Twave undeterminable
  • Causes Rheumatic fever, mitral valve stenosis,
    cad. HTN, MI, hyperthyroidism, COPD, CHF see
    pp. 604

52
A fib continued
  • Concern with A fib is the development of atrial
    thrombus and loss of atrial kick from ineffective
    atrial function.
  • Treatment Ca channel blockers and anti-
    arrhythmics to convert, beta blockers to lt HR,
    anticoagulants to prevent embolization.
  • Synchronized cardioversion

53
Atrial Fibrillation
  • - - 5 to 6 times more likely to have stroke
  • - - atrial rate 300 to 600 times/minute
  • --prolonged A-Fib may stretch weaken
  • heart muscle
  • - - symptoms lightheaded, very tired,
  • SOB, diaphoretic, chest
  • pain,

54
Afib causes
  • Chocolate large amounts contains theobromine, a
    mild cardiac stimulant.
  • - sleep apnea
  • - athletes more prone (enlarged heart)
  • - tall athletes (esp basketball players)
  • - aging heart
  • - men more than women
  • - sleeping on left side or stomach
  • etc.

55
A-fib treatment
  • ASA not as effective as Coumadin in preventing
    strokes.
  • ASA less likely to cause abnorm bleeding
  • since hemorrhagic stroke increases with age
    is also increased by taking Coumadin, some Drs.
    may switch older pts from Coumadin to ASA.

56
A Fib electrical cardioversion
  • High risk of forming clots causing stroke
  • Anticoagulants taken before treatment and 3-4
    weeks post treatment
  • If life-threatening, may need Heparin IV before
    cardioversion
  • Best time recent A fib

57
Atrial flutter
Atrial rate of 250-450 bpm ventricular rate
varies Atrial rhythm is regular ventricular rate
is irregular No identifiable p waves P wave is
not measurable Qrs 0.10 or less usually
58
Paced beat
Pacer spike should fall before the P wave unless
a dual Chamber pacemaker if it does not there
could be a problem
59
PAC
60
PAC premature atrial contraction
  • Premature depolarization of atrial origin
  • P wave may be buried in T wave
  • A pause follows and SA node will start new cycle
    of sinus beats
  • Indicates atrial irritability
  • No risk if occasional
  • If 6 or more per minute, indicates atrial
    tachycardia
  • Treat digitalis, calcium channel blockers, beta
    blockers

61
Premature ventricular conduction (PVC)
Extra beat Types uniformgo the same
direction multifocal go in different
direction R on Twhen the pvc fall on the
preceding twave couplet 2 pvcs
together bigeminy pvc every other
beat trigeminypvc every third beat
62
PVCs (unifocal)
63
PVCs (multifocal)
64
PVC ventricular origin
  • Complex is wide followed by compenatory pause
  • An irritable focus in ventricle initiates a
    contraction before normally expected beat.
  • Acute MI most common cause
  • QRS is wide and bizarre
  • Risks increasing myocardial irritability,
    leading to increased freq. of PVCs
  • Can occur as bigeminy (every other beat)
  • or short runs

65
Ventricular tachycardia
Monomorphic beats are same size and
shape Polymorphic different size and shape
66
V-tach
  • Advanced irritability of ventricles due to ASHD,
    CHF, acute MI electrolye imbal. Hypoxia,
    acidosis,occas drugs
  • RISKS low to no Cardiac output
  • Nursing Interventions monitor, if pt
    unconscious,immed. defib

67
Torsades de pointe
This is a polymorphic VT Usually electrical
imbalance in nature r/t NA or K
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69
Torsade de pointes
  • Will see prolonged QT interval when in sinus
    rhythm
  • Will see prominent U wave
  • If lasts gt10 seconds pt will progress to
    unconsciousness, life threatening with
    ineffective cardiac output
  • TREATMENT IV magnesium

70
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71
Ventricular Fibrillation
Rate can not be determined because of no
identifiable waves Rapid chaotic rhythm with no
pattern No p waves No PR interval No QRS
72
Vtach/Vfib
  • Both can be life threatening
  • VT V HR 100-250 bpm
  • Causes AMI, CAD, hypokalemia, dig toxic
  • S/S palpitations, dizzy, angina, ltLOC
  • Treatment assess for pulse, if none, defib
  • VFRate undeterminable Cause same
  • Treatment CPR

73
V-fib
  • May occur after MI
  • Extensive ventricular irritability
  • Very little cardiac output
  • Death within 4 to 8 minutes
  • TREATMENT immediate defibrillation
  • immed defib at 200 J
  • if unsuccessful, repeat at 300 J
  • If unsuccessful, repeat at 360 J
  • CPR

74
Asystole
75
Asystole and PEA
  • CPROxygen
  • Epinephrine 1 mg IV/IO (repeat 3-5 minutes)
  • May give Vasopressin 40U IV/IO to replace
  • 1st or 2nd dose of epinephrine
  • Consider Atropine 1 mg IV/IO Repeat every 3 to 5
    min (up to 3 doses)

76
What arrthymias are considered PEA?
  • See an organized or semi-organized rhythm BUT NO
    PULSE
  • This includes
  • - idioventricular rhythms
  • - ventricular escape beats
  • - postdefibrillation
    idioventricular

77
http//www.campaignfornursing.com/events/WINNERS/p
ennsylvania/
78
ST elevation
79
12 lead ekg
  • The electrocardiogram (EKG) is a device that
    receives electric impulses from the body and
    changes them into a monitor tracing that can be
    analyzed to find problems with electrical
    conduction in the heart. The EKG simply picks up
    electrical impulses it does not read mechanical
    activity. When a patient has ischemia, injury or
    necrosis to the heart muscle, the electrical
    impulses change in the area involved. Nurses can
    analyze the electrical changes and determine if
    they indicate mechanical dysfunction.

80
  • The EKG is simply a volt meter that picks up
    electrical signals. Therefore, anything that
    interferes with electrical conduction can cause
    changes in the EKG. These variables can be
    divided into three main categories
  • 1) physiological variables not specific to the
    heart (ie. pulmonary embolism, increased
    intracranial pressure)
  • 2) electrical interference (ie. poorly placed
    lead)
  • 3) ischemia, injury, or infarction

81
5 Steps to 12 Lead Interpretation1. Assess
regularity and speed2. Look for signs of
infarction3. Present in gt1 lead, but not all?4.
Assess associated conditions5. Correlate with
clinical condition
82
Normal EKG
83
MI
84
Polymorphic VT
85
VFIB
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92
  • http//nursebob.com/
  • http//www.usfca.edu/fac_staff/ritter/ekg.htm
  • http//ems-safety.com/12-lead-ekg.htm

93
Rhythms for Cardioversion
  • A-fib
  • A-flutter
  • Supraventricular tachycardia

94
Electrical cardioversion
  • treatment of choice for hemodynamically unstable
    tachydysrhythmia
  • It is used for the treatment of unstable
    ventricular tachycardia with a pulse
  • With cardioversion potentially prevents
    life-threatening dysrhythmias.
  • Cardioversion may either be a planned or emergent
    procedure.
  • Properly done cardioversion will correct the
    patients dysrhythmia with minimal discomfort and
    maximum safety.

95
Chemical cardioversion
  • Indication A. Rapid conversion of atrial
    fibrillation and atrial flutter. B. Ibutilide is
    moderately effective in patients who have atrial
    flutter.
  • 2. Action. A. Ibutilide prolongs action
    potential duration. B. Blocks the rapidly
    activating component of the delayed rectifier
    potassium current. C. No significant effect on
    heart rate, PR interval, or QRS interval D.
    Route of elimination hepatic.
  • 3. Administration. A. Ibutilide is available in
    10 mL vials containing 0.1 mg/mL (1 mg
    total). B. For intravenous administration, the
    recommended dose of Ibutilide is 1mg over a 10
    minute period in patients weighing gt 60 kg C.
    Patients weighing lt 60 kg, the recommended dose
    is 0.01 mg/kg initially, with a second dose of
    the same strength 10 minutes later if
    necessary. D. Ten minutes after the end of the
    initial infusion, a second 10 minute infusion of
    equal strength can be given if the arrhythmia has
    not terminated.

96
  • Cautions. A. Prolong ventricular
    repolarization B. Carries a risk of excessive QT
    prolongation C. Acquired long-QT syndrome D.
    Associated polymorphic ventricular tachycardia
    (torsade de pointes) E. Careful patient
    selection and clinical monitoring during drug
    administration.
  • 5. Contraindications. A. QT interval exceeding
    440ms B. Bradycardia C. Electrolyte
    disturbances D. Other QT-prolonging drugs
  • 6. Adverse Effects. A. Ventricular
    tachycardia B. Premature ventricular
    complexes C. Hypotension D. Bundle branch
    block E. Atrioventricular

97
  • Post cardioversion care
  • 1. generally the care for a patient is the same
    as for defibrillation.
  • 2. If it is a elective procedure, digoxin is
    withheld for 48 hours prior to prevent
    dysrhythmias after the procedure.
  • 3. Assess airway and LOC

98
Indications for pacemaker
  • Temporary
  • -symptomatic bradycardia (not controlled by
    meds)
  • - ant MI
  • - drug overdose (dig, beta blocker)
  • Permanent
  • - 2nd degree Mobitz Type II
  • - 3rd degree Block
  • - symptomatic bradycardia, arrhythmias
  • - suppress tachyarrythmias

99
Modes of Pacing
  • Synchronous (demand )Mode
  • - sensitivity is set to patient beats
  • - pacer will fir when pt rate goes below
  • that what is set
  • Asynchronous pacing
  • - for asystole, or profound bradycardia
  • - does not sense any pt beats
  • - fires at set rate no matter what pt
    rate is

100
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101
Chambers that can be paced
  • Atrium
  • Ventricle
  • Dual (both atrium and ventricle)
  • ICD (Implantable Cardioverter Defibrillator)

102
Dual Paced
  • Atrial Pace, Ventricular Pace (AP/VP)

V-A
AV
V-A
AV

103
Implant Cardioverter Defibrillator ICD
104
ICD
  • - prevents sudden cardiac death due to
  • V-tach or V-fib.
  • Pt can feel the shock
  • -defib felt like kick in the chest
  • that lasts 1 second
  • - cardiovert feels like thump in chest
  • - pt doesnt feel pacing

105
Problems with pacers
  • Failure to fire
  • Failure to capture
  • Undersensing (low battery, poor lead
  • position)
  • Oversensing (turn down output, magnetic
  • interference)

106
Operative failures with pacers
  • Pneumothorax
  • Pericarditis
  • Infection
  • Hematoma
  • Lead dislodgement (seen on X-ray)
  • Venous thrombosis (rare but would see
  • unilateral edema to arm on same side
  • as pacer)

107
Pt Education
  • 1. carry ID card (Xray code seen in standard
    chest Xray)
  • 2. not allowed to drive for 1 month
  • 3. no metal detectors or no longer than nec.
  • 4. MRI interrupts pacing-cant get one for some
    time if new
  • 5. No power generators (welding)
  • 6. microwave questionable
  • 7. radiotherapy (may damage circuits) The
  • pacer may need to be surgically moved if in
  • path of radiation field.
  • 8. TENS (transcutaneous electrical stimulation)
    interferes
  • may need reprogramming
  • 9. Cell phone use in opposite ear of pacer and
    store away
  • from side of pacer

108
EP with Ablation
  • An electrophysiology study is simply a study
    of the electrical function of your heart.

109
  • A (IV) catheter may be placed and be used to
    continuously administer fluids.
  • An EP team doctor will explain why the procedure
    is necessary and what risks are involved for you.
  • Obtain consent
  • Prior to the EP study, CHG Bath performed.
  • The most common site used is the groin, or the
    area at the crease of the leg about midway
    between the center of your body and your hip.
    Occasionally the forearm, neck or collarbone
    areas are used

110
  • NPO after midnight the night before the test.
  • If the test is not scheduled until later in the
    day, may have a clear liquid breakfast
  • All your medicines will be reviewed, and some may
    be withdrawn prior to the test.
  • . It is important for pt to describe sensations
    experienced during the test.
  • Dentures and Glasses may be worn
  • An initial EP study takes an average of two and
    a half hours however, they may range from one to
    six hours.

111
  • After the test, the catheters will be removed.
    Firm pressure will be applied over the puncture
    site for approximately 15 minutes.
  • Flat bed rest is necessary for two to eight hours
    after the study. Assessment of site needs
    performed.
  • You will be in the room frequently during the
    first hour after the study to take blood
    pressure, heart rate, and check the insertion
    site for signs of bleeding. The pulses and
    temperature of the feet will also be checked.
  • Pt will be instructed to apply pressure firmly to
    the insertion site if cough or sneeze and while
    using the bedpan or urinal.
  • Administer pain meds as needed for discomfort

112
Bundle Branch Blocks Diagnosed with 12 lead
EKG most common cause acute MI
  • Right bundle branch block
  • - impulse travels through left ventricle first,
    then activates right ventricle (gives am M
    shaped complex
  • Left bundle branch block
  • --impulse first depolarizes right side of
    heart then the left ventricle (gives deep, wide
    V shaped complex

113
Bundle Branch Blocks
  • Risks can deteriorate to 3rd degree block
  • then treat with atropine or pacemaker
  • Pt can be asymptomatic until progresses

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115
Hyperkalcemia
116
hypokalcemia
117
Intro to ACLS
118
Primary Survey
  • Airway Open airway, look, listen, and feel for
    breathing
  • Breathing If not breathing slowly give 2 rescue
    breaths. If breaths go in continue to next step.
  • Circulation Check the carotid artery (Adult) for
    a pulse. If no pulse begin CPR.
  • Defibrillation Search for and Shock
    V-Fib/Pulseless V-Tach

119
Adult ACLS Secondary Survey ABCDs (abbreviated)
  • Airway Intubate if not breathing. Assess
    bilateral breath sounds for proper tube
    placement.
  • Breathing Provide positive pressure ventilations
    with 100 O2.
  • Circulation If no pulse continue CPR, obtain IV
    access, give proper medications.
  • Differential Diagnosis Attempt to identify
    treatable causes for the problem.

.
120
AED
  • An AED is a device used in cardiac arrest, or
    sudden cardiac death, when the hearts electrical
    activity is disorganized and there is no
    effective pumping of blood. The AED is capable of
    recognizing the heart's electrical activity, and
    determining if an electric shock is required. If
    the shock is needed, a voice prompt in the AED is
    activated, telling the rescuer to push a button
    to deliver the shock

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122
  • http//acls.net/quiz/mi_stroke_1.htm

123
stress
  • Common responses can include
  • Feeling a sense of loss, sadness, frustration,
    helplessness, or emotional numbness
  • Experiencing troubling memories from that day
  • Having nightmares or difficulty falling or
    staying asleep 
  • Having no desire for food or a loss of appetite
  • Having difficulty concentrating 
  • Feeling nervous or on edge

124
Teaching to cope
  • Reach out and talk.
  • Express yourself.
  • Watch and listen.
  • Stay active.
  • Stay in touch with family.   
  • Take care of yourself.

125
ANY QUESTIONS???
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