IVY TECH COMMUNITY COLLEGE NSG 108, TRANSITION FOR THE PARAMEDIC TO THE ASSOCIATE OF SCIENCE IN NURSING COURSE TITLE: Transition for the Paramedic to the Associate of Science in Nursing COURSE NUMBER: NSG 108 PREREQUISITES: Admission to the Associate of Science of Nursing Program COREQUISITES: NSG 109 Transition for the Paramedic to the Associate Science in Nursing Lab/Clinical DIVISION: Health Sciences PROGRAM: Nursing CREDIT HOURS: 5 CONTACT HOURS: Lecture: 80 DATE OF LAST REVISION: Spring, 2008 EFFECTIVE DATE OF THIS REVISION: Summer 08 CATALOG DESCRIPTION: Examines the transition to the role of the registered nurse. Identifies components of the nursing program philosophy. Provides an overview of the five components of the nursing process, emphasizes the assessment component. Introduces data analysis and nursing diagnoses. Reviews etiology, pathophysiology, clinical manifestations, and the diagnostic testing of common alterations in health within the context of all body systems. Introduces mental health concepts and therapeutic communications / milieu management. MAJOR COURSE LEARNING OBJECTIVES: Upon successful completion of this course the student will be expected to: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Describe the basic components of the program philosophy. Describe the function of the members of the health care team. Differentiate the roles of the licensed practical nurse and the registered nurse. Describe historical and current milestones that have influenced today’s health care environment. Describe basic ethical and legal principles utilized in providing patient care. Explain the five components of the nursing process within the context of the wellness-illness continuum. Identify fundamental principles of the teaching-learning process. Identify basic physiological, psychosocial, cultural, intellectual, and spiritual needs common to all patients across the lifespan. Identify basic nursing interventions utilized to meet basic physiological, psychosocial, cultural, intellectual, and spiritual needs of patients. Identify fundamental principles of communication necessary for interactions with patients, their significant others, and members of the health care team. Describe fundamental principles of nursing documentation. Practice fundamental principles of drug dosage calculation. Identify basic nutritional concepts. Identify techniques utilized by the nurse to assess physiologic function of all body systems. Identify clinical manifestations of common alterations in health. Describe the etiology and pathophysiology of common alterations in health. Describe the role of the nurse in the therapeutic management of patients undergoing diagnostic tests utilized in the assessment of health status. NSG108 Syllabus Summer 08 1 18. Discuss the roles of the licensed practical nurse and registered nurse in analyzing data to identify patient needs. 19. Describe the role of the registered nurse in determining appropriate nursing diagnoses and collaborative problems associated with common alterations in health. 20. Describe introductory mental health concepts and therapeutic communication/milieu management. REQUIRED TEXTS AND INSTRUCTIONAL MATERIALS: Boyer, M.J. (2008). Study guide to accompany Brunner and Suddarth’s texbook of medical-surgical nursing, 11th ed., Philadelphia: Lippincott Carpenito-Moyet, L. (2008). Understanding the nursing process. Concept mapping and Care Planning for Students. Philadelphia: Lippincott Williams & Wilkins. Pickar, G. (2007). Dosage Calculations: Ratio-Proportion Method. (2nd ed.). Clifton Park, NY: Thomson Delmar Learning. Smeltzer, S. C., et al. (2008). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Texas Instruments calculator, Model # TI-503 SV OPTIONAL TEXTS & REFERENCES: Carpenito-Moyet, L. (2007). Understanding the nursing process. Concepts mapping and care planning for students. Philadelphia: Lippincott Anatomy & Physiology text Nursing or medical dictionary of choice Taylor, C. (2008), Fundamentals of Nursing: The art and science of nursing care, 5th ed., Philadelphia: Lippincott. Taylor, C. (2008)., Study Guide to Fundamentals of nursing: the art and science of nursing care, 5th ed., Philadelphia: Lippincott. ADA STATEMENT: Ivy Tech Community College seeks to provide effective services and accommodations for qualified individuals with documented disabilities. The goal of Disability Support Services (DSS) is to provide opportunities for equal access in college programs, services, and activities. DSS assists students with disabilities in achieving their education goals through such services as academic and career counseling, adaptive testing, tutoring, note taking, interpreting, and test proctoring. Please contact Cyndi Cates at 812429-1386; her office is in room 108B. NSG108 Syllabus Summer 08 2 DISABILITIES SERVICES COORDINATOR/OFFICE: If you need an accommodation because of a documented disability, you are required to register with Disability Support Services at the beginning of each semester. Please contact Cyndi Cates at 812-4291386; her office is in Room 108. If you will require assistance during an emergency evacuation, notify your instructor immediately. Look for evacuation procedures posted in your classrooms. ACADEMIC HONESTY STATEMENT: The College is committed to academic integrity in all its practices. The faculty value intellectual integrity and a high standard of academic conduct. Activities that violate academic integrity undermine the quality and diminish the value of educational achievement. Cheating on papers, tests, or other academic works is a violation of College rules. No student shall engage in behavior that, in the judgment of the instructor of the class, may be construed as cheating. This may include, but is not limited to, plagiarism, or other forms of academic dishonesty, such as the acquisition without permission of tests or other academic materials, and/or distribution of these materials and other academic work. This includes students who aid and abet as well as those who attempt such behavior. TESTING POLICY: Refer to Nursing Student Handbook: Nursing Program Test Policies. TEST REVIEW: Each student is encouraged to challenge answers to test questions if there is a disagreement. THIS MUST BE IN WRITING RELATING THE RATIONALE FOR THE DISAGREEMENT AND SUBMITTED TO THE INSTRUCTOR WITHIN SEVEN (7) DAYS AFTER THE TEST WAS GIVEN. Please list your references used with page numbers to support your challenge. If the challenge is not submitted within seven (7) days after the testing date, the challenge will not be considered. This supports the rationale to view your tests within the week after testing to evaluate if there are disagreements. LATE ASSIGNMENTS: Refer to Handbook: Written Assignments MAKE-UP POLICY: Refer to handbook: Nursing Program Test Policies ATTENDANCE POLICY: Refer to Handbook: Classroom and Lab Attendance Policy WITHDRAW DATE: METHOD(S) OF INSTRUCTIONAL DELIVERY: Lecture, handouts, audiovisuals, 1:1, demonstrations, review of exams, guest speakers, independent study, collaborative learning, and computer-assisted instruction. NSG108 Syllabus Summer 08 3 METHOD(S) OF EVALUATION: Evaluation of student progress, in terms of the achievement of Course Objectives, is an on-going process carried on through observation of student performance in written work, exams, Computer Assisted Instruction (CAI), and class attendance/participation. Failure to complete course requirements will result in failure in this course. It is the responsibility of the student to keep a record of his or her course grade point average. POINTS Exam I Exam II Exam III Exam Points Leisure Learning I Leisure Learning II Leisure Learning Points Possible Points 60 60 60 180 30 30 60 Only after achieving 135 points (75.0%) or higher on exams will the additional leisure learning activities be factored into the grade. Failure to obtain 135 points on the exams will result in a grade based on 180 points. Final Grade will be calculated with 240 points possible after achieving 75.0% on the exams. EXAMS: There will 3 exams with 60 questions each. One minute per question will be allowed for each exam. Two leisure learning assignments are equivalent to one exam for this course. Leisure Learning assignments are due by 1300 on the two dates assigned in the syllabus. RIGHT OF REVISION: The instructors or the nursing program may revise any matter described in this syllabus at any time without publishing a revised version. Students will be made aware of the revision in writing if they occur. This syllabus and its provisions are not in any way a contract between the student and Ivy Tech Community College. NSG108 Syllabus Summer 08 4 COURSE OUTLINE: MANAGEMENT OBJECTIVES The student will be able to: 1. Identify the essential components of the nursing process in order to prepare a plan of care. 2. Review the standards of patient rights, ethical practice, informed consent, and confidentiality. 3. Identify the concepts of management: delegation, supervision, ethical practice and consultation. 4. Recognize the importance of establishing priorities for effective management of patient care. PERIOPERATIVE OBJECTIVES The student will be able to: 1. Describe the nurse’s role in managing care for a patient during the perioperative period. 2. Recognize the classification of surgeries according to purpose and degree of urgency. 3. Review the use of nursing process in the pre-operative health assessment and preparation of surgical patients. 4. Identify the various types of pre-op medications given before surgery and explain the purpose. 5. Define the nursing assessment in the immediate post-operative care during the recovery period. 6. Identify general postanesthesia discomforts and nursing intervention for each. 7. Identify factors predisposing to wound infection. 8. Describe the clinical decision-making used by the nurse to prevent and recognize postoperative complications. *Please review learning objectives at the beginning of each chapter. Week A. B. C. D. Content Introduction to data analysis Introduction to ID and prioritizing nursing problems Management of patient care Plan of care and interventions for the surgical pt. o Preoperative Care o Intra operative Care o Postoperative Care Activity Brunner Ch1: pp 10-33 Chapters 18, 19, 20 HEMATOLOGY/IMMUNOLOGY OBJECTIVES Objectives - the student will: 1. Assess for, and recognize, the signs and symptoms of a hematological deviation. 2. Apply the nursing process to the management of a patient with a hematological disorder. 3. Recognize the role teaching/learning plays in caring for a patient experiencing a hematological deviation. 4. Recognize the nursing competencies in primary, secondary, and tertiary care of the patient and family with a hematological disorder. 5. Relate the psychosocial, developmental and cultural considerations in patients’ achievement of developmental tasks with a hematological disorder. *Please review learning objectives at the beginning of each chapter. A. Application Of The Nursing Process B. Etiology, pathophysiology, clinical manifestations and diagnostic NSG108 Syllabus Summer 08 5 Brunner Chapters 33 testing C. Hematology/ Immunology o Anemias o Erythrocytosis o Polycythemia o Thrombocytopenia o Hemophilia o Inflammation, Infection o Mononucleosis o Allergies D. Ordered Plan of Treatment E. Teaching Needs of Client/Family pp 1045 – 1066, 1103-1111, 10871092, 1865-1876, 2490-2500 INTEGUMENTARY OBJECTIVES: The student will be able to: 1. Recall the assessment criteria for patients with deviations related to skin. 2. Explain the etiology, manifestations and management of specific integumentary disorders. 3. State the medical/surgical plan of care for patients with these disorders. 4. Demonstrate competency with the Braden Scale for skin assessment & intervention. *Please review learning objectives at the beginning of each chapter. A. Nursing assessment of integumentary system B. Etiology, pathophysiology, clinical manifestations and diagnostic testing o Infectious Skin Disorders o Dermatoses o Stasis Ulcers o Pressure Ulcers o Neoplasms o Eczema o Application of Nursing Process o Secretory, infectious, and blistering disorders o Collaborative and nursing interventions o Application of the Nursing Process o Teaching Needs of Client/Family Smeltzer pp. 19451978, 209-214 FLUID/ELECTROLYTES/ACID BASE OBJECTIVES The student will be able to: 1. Review the basic physiologic mechanisms responsible for maintaining water/fluid and electrolyte and acid-base imbalances. 2. Apply nursing process to the patient experiencing an acid-base and/or water/fluid and electrolyte imbalance. 4. Describe the role of the nurse in caring for a patient with a fluid and electrolyte/acid base imbalance. 5. Recognize the role teaching/learning plays in caring for a patient experiencing fluid and electrolyte and/or acid base Imbalance. *Please review learning objectives at the beginning of each chapter. A. Nursing Assessment of fluid, electrolyte and acid/base balance B. Etiology, pathophysiology, clinical manifestations, diagnostic NSG108 Syllabus Summer 08 6 Smeltzer pp. 308-352 testing C. Fluid Imbalances D. Electrolyte Imbalances E. Acid-Base Imbalances RENAL OBJECTIVES Objectives – the student will: 1. Apply nursing process to the management of patient with renal disorders. 2. Develop a teaching care plan for patients experiencing a renal/urinary disorder. 3. Relate the collaboration of the health care team when caring for a patient with renal failure. *Please review learning objectives at the beginning of each chapter. A. Nursing assessment of urinary and renal function B. Etiology, pathophysiology, clinical manifestations, diagnostic testing: o UTI/ Cystitis, Pyelonephritis, Nephritis o Hydronephrosis o Renal Failure o Cancers o Disorders of the Kidney and Ureters o Renal Calculi o Polycystic Disease o Hydronephrosis o Urinary Retention o Disorders of the Bladder and Urethra o Urinary Retention o Incontinence o Application of Nursing Process o Ordered Plan of Treatment o Teaching Needs of Client/Family EXAM I Smeltzer pp. 1515-1521, 15521560, 1570-1607 CARDIAC OBJECTIVES The student will be able to: 1. Apply the concepts and principles of medical-surgical nursing care as it relates to cardiac health and illness. 2. Use the nursing process as a framework when caring for a patient with a cardiac illness. 3. Apply teaching/learning principles for the prevention or maintenance of cardiac disease. A. Nursing assessment of CV function Smeltzer Ch. 28-32 B. etiology, pathophysiology, clinical manifestations & diagnostic testing: Hole’s A&P Ch. 17 o CAD/MI o Dysrhythmias C. Vascular o Infectious/Inflammatory disorders of the vessels o Thromboemolic disorders o Phlebitis, arteritis o Hypertension o Vascular Insufficiency o Aneurysm NSG108 Syllabus Summer 08 7 D. Cardiac o CAD o Heart Failure o Cardiomyopathy o Valvular Disorders o Infection/Inflammatory disorders of the heart E. Cardiovascular Surgeries F. Application of Nursing Process G. Ordered Plan of Treatment H. Teaching Needs of Client/Family RESPIRATORY OBJECTIVES The student will be able to: 1. Apply the concepts and principles of medical-surgical nursing care as it relates to respiratory health and illness. 2. Use the nursing process as a framework when caring for a patient with a respiratory illness. 3. Apply teaching/learning principles for the prevention or maintenance of respiratory disease. *Please review learning objectives at the beginning of each chapter. A. Nursing assessment of respiratory function B. Etiology, pathophysiology, clinical manifestations and diagnostic testing: C. Sleep Apna D. ARDS E. Atelectasis F. Pneumothorax G. Lung Cancer H. Environmental Lung Diseases I. Respiratory infections J. Upper Respiratory Disorders o Structural o Inflammatory o Obstructive: sleep apnea K. Chronic Obstructive Pulmonary Disease o Chronic bronchitis o Emphysema o Asthma L. Lower Respiratory Problems M. Infections: pneumonia N. Application of the Nursing Process O. Teaching Needs of Client/Family Smeltzer Ch 22 p589-607, Ch 23 625-656, Ch 24 685-720 (all) “Med-Surg Mania: Respiratory” GASTROINTESTINAL OBJECTIVES The student will be able to: 1. Formulate a nursing plan of care for a deviation with the need for elimination. 2. Describe a health teaching plan that will promote and help maintain function of the gastrointestinal system. 3. Apply the nursing process to the management of a patient with a gastrointestinal disorder. NSG108 Syllabus Summer 08 8 *Please review learning objectives at the beginning of each chapter. A. Nursing assessment of the GI/Hepatic/Biliary/Pancreatic function Leisure B. Etiology, pathophysiology, clinical manifestations and diagnostic testing: Learning 1. Disorders of the Upper Gastrointestinal Tract I Due o GERD o Hiatal Hernia o Esophogeal Varicies o Peptic Ulcer Disease o Gastroenteritis 2. Disorders of the Lower Gastrointestinal Tract o Irritable Bowel Syndrome o Hernias o Intestinal Polyps o Hemorrhoids o Parasitic/Helminthic Infection o Inflammatory Bowel Disease o Hemorrhoids o Parasitic/Helminthic Infection o Cancer of the GI Tract o Surgical Diversions 3. Disorders of the Accessory Structures o Cholecycstitis o Cholelithiasis o Fatty Liver Disease o Cirrhosis o Pancreatitis 4. Nutritional Disorders o Malnutrition o Obesity C. The Client with an Ostomy D. Application of Nursing Process E. Teaching Needs of Client/Family Smeltzer Ch: 35, pp1162-1166 Ch 36, all Ch 37, all Ch 38, all Hole’s A&P Ch. 17 & 18 EXAM II DIABETES & ENDOCRINE OBJECTIVES The student will be able to: 1. Develop a teaching care plan for the diabetic patient and family about the variations in diet and exercise, medication, and monitoring. 2. Use the nursing process as a framework in the care of the patient with an endocrine condition. 3. Compare the hyper and hypo conditions of each endocrine gland, and accompanying management and Interventions. *Please review the learning objective at the beginning of each chapter. A. Nursing assessment of the Endocrine System B. Etiology, pathophysiology, clinical manifestations and diagnostic testing: C. Diabetes o Review of Physiology of the Pancreas NSG108 Syllabus Summer 08 9 Lecture/independent study Smeltzer Ch 41 1376-1421 o o o o o o o Definitions of diabetes mellitus Metabolic Syndrome Psychosocial Considerations Developmental Considerations Current Therapies Diet therapies Exercise Drug therapies Monitoring options Education patient/family Hyper and hypoglycemic interventions Teaching Needs of Client/Family Application of the Nursing Process Teaching Needs of Client/Family II. Endocrine Disorders Classroom discussion of care of the patient with diabetes in the clinical setting. Smeltzer Ch 42, all A. B. C. D. Anatomy & Physiology Psychosocial Considerations Developmental Considerations Pituitary Gland Dysfunction o Current therapies o Nursing Plan of Care E. Thyroid Gland Dysfunction o Current Therapies o Nursing Plan of Care F. Parathyroid Dysfunctions o Current therapies o Nursing Plan of Care G. Adrenal Gland Dysfunction o Current therapies o Nursing Plan of Care H. Application of the Nursing Process I. Teaching Needs of Client/Family SENSORY DISORDER OBJECTIVES Objectives – the student will: 1. Describe the assessment findings for patients with deviation of visual/auditory. 2. Relate nursing process to safety concerns. 3. Identify communication barriers and interventions to assist in coping. *Please review learning objectives at the beginning of each chapter. A. Nursing assessment of Sensory System B. Etiology, pathophysiology, clinical manifestations and diagnostic testing Eye Disorders o Infection/Inflammation o Cataract/Glaucoma/Retinal Problems o Trauma o Refractive Errors NSG108 Syllabus Summer 08 10 Brunner Chapters: 58, 59 Hole’s A&P Ch. 12 o Macular Degeneration o Blindness Ear Disorders o Otitis Media o Mastoiditis o Impacted Cerumen o Otosclerosis o Trauma o Tinitis o Labyrnthitis o Meniere’s Disease o Deafness C. Application of Nursing Process D. Ordered Plan of Treatment SEXUALLY TRANSMITTED DISEASE & REPRODUCTIVE OBJECTIVES The student will be able to: 1. Recognize the physiological and psychological challenges for patients experiencing a STD. 2. Apply the nursing process to the management of a patient with a reproductive disorder/STD. 3. Recognize the role teaching/learning plays in caring for a patient with a reproductive disorder/STD. 4. Design a plan for the patient’s experiencing reproductive disorders and STD’s. ** *Please review learning objectives at the beginning of each chapter. A. Nursing assessment of reproductive function & STD’s B. Etiology, pathophysiology, clinical manifestations and diagnostic testing o STD’s o Infection C. Female Disorders o Menstrual Disorders o Vaginal Disorders o Uterine and Cervical Disorders o Ovarian Disorders o Female Reproductive Cancers o Breast Disorders o Breast Cancer o Infertility D. Male Disorders o Testicular Disorders o Penile Disorders o Prostatic Disorders o Male Reproductive Cancers E. Ordered Plan of Treatment F. Application of the Nursing Process G. Teaching Needs of Client/Family NSG108 Syllabus Summer 08 11 Smeltzer Ch 47, 1744-1752, 1773-1776 Ch 49, 1661-1682, Ch 70, 2475-2508 MUSCULOSKELETAL OBJECTIVES The student will be able to: 1. Use the nursing process as a framework for care of the person with a musculoskeletal condition. 2. Explain pre- and post-op management of patients and families with musculoskeletal disorders. 3. Describe the rehabilitation and health teaching needs for a patient experiencing common musculoskeletal trauma. 4. Discuss a teaching care plan for an individual with a musculoskeletal disorder. *Please review the learning objectives at the beginning of each chapter. A. Nursing assessment of Musculoskeletal System B. Etiology, pathophysiology, clinical manifestations and diagnostic testing: C. Disease Process o Injury/Trauma o Osteoporosis/Osteogenesis Imperfecta o Paget’s Disease o Carpal Tunnal o Ganglions o Neoplasms o Disorders of the foot o Muscular Dystrophies o Fractures o Amputations o Sports-Activity & Related Trauma Knee injury Dislocations Strains/Sprains Rotator Cuff Injury o Osteoarthritis o Joint Replacement D. Traumatic conditions o Contusions, strains, o Dislocation o Fractures o Amputations E. Surgical plan of care E. Degenerative conditions o Osteoporosis o Paget’s disease F. Inflammatory conditions o Osteomyelitis G. Arthritis & Connective Tissue conditions o Rheumatoid arthritis o Osteoarthritis H. Teaching Needs of Client/Family I. Application of the Nursing Process NSG108 Syllabus Summer 08 12 Brunner Ch 66, 67 68 & 69 CAI: Adult Health Nursing Concepts – Musculoskeletal Hole’s A&P Ch. 7&8 NEUROLOGICAL DISORDER OBJECTIVES The student will be able to: 1. 2. 3. Describe the nursing needs of patients with various neurologic dysfunctions. Use the nursing process as a framework for care of the patient with neurologic disorders. Identify family teaching in preparation for home care of the patient with a neurologic injury. *Please review the learning objectives at the beginning of each chapter. A. Nursing assessment of the neurologic system Leisure B. Etiology, pathophysiology, clinical manifestations and diagnostic testing: Learning Central and Peripheral Nervous System Disorders II o Headaches Due o Seizures o CNS Infections o Parkinsons’s o Alzheimers o Huntington’s o Stroke o Aneurysm o Spinal Cord Injury o Herniated Disc o Multiple Sclerosis o ALS o Guillain-Barre o Myasthenia Gravis o Neuritis o Neuropathy o Trigeminal Neuralgia o Bell’s Palsy o Neoplasms C. Application of the Nursing Process D. Teaching Needs of Client/Family Cancer Development The student will be able to: 1. Identify major pathological factors associated with oncologic disorders. 2. Describe nursing care needed in preparing for diagnostic procedures and tests of oncologic disorders. 3. Describe nursing assessment of patients with oncologic disorders. 4. List nursing diagnoses associated with selected oncologic conditions. *Please review the learning objectives at the beginning of each chapter. A. Nursing assessment of the patient with a malignant B. Etiology, pathophysiology, clinical manifestations and diagnostic testing C. Overview of oncologic concepts o Pathophysiology o Warning Signs NSG108 Syllabus Summer 08 13 Smeltzer Ch 61, 2190-2202, Ch 64, all Ch 65, 2311-2331 Hole’s A&P Ch. 11 D. E. F. G. o Nursing Assessment of hematologic and immune function o Diagnostic testing o Etiology, pathophysiology, clinical manifestations: o Anemias o Erythrocytosis o Polycythemia o Thrombocytopenia o Hemophelia Inflammation, infection Allergies Autoimmune disorders HIV Psychiatric Disorders The student will: 1. Demonstrate understanding of the mental health continuum. 2. Provide examples of therapeutic and non-therapeutic communication. 3. Explain basic principles of milieu management. 4. Differentiate cultural considerations when providing care for a patient with a mental health disorder. 5. Demonstrate understanding of legal issues encountered in caring for the patient with a mental health disorder. 6. Differentiate classifications of mental health disorders based on DSM criteria. 7. Differentiate between the four types of mental health disorders. *Please review the learning objectives at the beginning of each chapter. A. Nursing assessment of mental health status B. Etiology, pathophysiology, clinical manifestations and diagnostic testing C. Mental Health Conditions D. The Mental Health Continuum E. Assessment of Mental Health Status o MMSE o Observation of Behaviors F. Therapeutic Communication G. Milieu Management H. Cultural Considerations I. Legal Aspects of Mental Health Care o Voluntary vs. Involuntary Inpatient J. Admissions o Competency Determination o Patient Rights and Restraint Usage K. The DSM Classification System L. Overview of Mental Health Disorders o Mood Disorders o Suicidal Patients o Thought Disorders o Personality Disorders M. Application of the Nursing Process N. Teaching Needs of Client/Family EXAM III NSG108 Syllabus Summer 08 14 Smeltzer, Chapter 7 Handouts This workforce solution was funded by a grant awarded under the President’s Community-Based Job Training Grants as implemented by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. 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