|
Here Is Some Practical Advice for the New
Nurse Practitioner
By Angela Nelson, RN, MSN, CCRN, CS,
ACNP
Advanced Practice Work Group
Congratulations! You're a new nurse
practitioner. You have finished school and passed your certification exam. Now,
you may be looking for a position.
Keep in mind that most NPs obtain their
first position through contacts during their clinical experiences, an
acquaintance or their current employer. So, don't rule out any of those
avenues-aggressively pursue leads from these sources.
Many NPs demonstrate to prospective
employers how they can fulfill a need that they have identified. This need may
be identified in a clinical rotation or with a current employer.
The Job Network
Attending conferences to speak with
exhibiting recruiters or networking at the local or state level, for example
through chapters or state organizations, are excellent ways to seek out career
possibilities. Often, job opening announcements are made at these meetings. One
source for locating local and state NP organizations is the Clinician Reviews
journal, which publishes an annual list in its December issue.
You can also find helpful links through
online listservs. For acute care NPs, the ANPACC listserv includes job
information from members nationwide. To subscribe, visit ANPACC@yahoogroups.com
and type ANPACC in the search area. A number of state and specialty area
listservs are also available. In addition, AACN offers a job posting section on
its Web site at www.aacn.org > Careers >Job Postings. Of course, newspapers and
professional publications are also valuable sources when searching for a job, as
are individual hospital Web sites.
Keep a record of the positions for which
you apply. Using a notebook where you can tape a copy of a job ad and notations
about your application status, such as an acknowledgment that your CV was
received, a call back or scheduled interview, is helpful. This record will help
you recall the particulars of a position, especially because you may not hear
from a potential employer for as long as eight weeks after submitting a CV.
Sending a follow-up thank you letter after an interview is not only courteous,
but also a good way to keep your name up front.
When negotiating for a position, do not
sell yourself or the profession short. Do not underestimate the value of your
nursing experience and how that experience will allow you to move up the scale
from novice to expert NP more quickly than someone with fewer years of
experience or experience not appropriate to the current position. You want to be
paid not only fairly but also at a higher rate than your current RN position.
Remember to negotiate for conference time and reimbursement, compensation for
on-call duties, professional organization dues and reimbursement for Drug
Enforcement Administration numbers, as well as the time frame and terms in which
salary increases will be considered.
Meeting Requirements
Be aware of your state and board
certification requirements regarding continuing education, including
pharmaceutical content. You can meet these requirements in a variety of ways.
For example, chapter meetings often feature speakers and offer CE units. In
addition, professional journals publish CE articles, and many pharmaceutical
companies offer CE units online or CD ROMs on which content can be reviewed and
submitted for CE credit at nominal or no cost. If you are employed at a
hospital, opportunities may exit to obtain free CE units. Although state,
national and specialty practice conferences may be more expensive, they provide
a great way not only to earn CE credits, but also to keep up to date on
information.
By the Numbers
You can apply for your DEA online at
www.usdoj.gov/dea > DEA Resources > For Physicians/Registrants > Registration.
You will need DEA Form 224. The fee is $210.
To apply for your Medicare Provider
Identification Number, contact your local carrier. A list of state carriers is
available on the American Academy of Nurse Practitioners Web site at
http://www.aanp.org.
Stretching Dollars
Is anything free? You can order
personalized prescription pads from a company called Medi-Scripts at (800)
387-3636. In addition, the Nurse Practitioner Prescribing Reference is offered
complimentary to certified NPs at (617) 923-8519. Many publications are offered
free to NPs, including two online: Consultant at www.consultantLive.com and
Advance for Nurse Practitioners at www.AdvanceforNP.com. You can also order
Clinician Reviews by calling (973) 916-1000.
Remember that you may be the first NP with
whom patients have contact. In fact, they may not even know what an NP is.
Therefore, it is important to always present yourself as professionally as
possible. First impressions are important and that first experience with an NP
may form a lasting impression for a particular individual. If we all strive for
our best, our profession will expand and grow by leaps and bounds.
Practice Resource Network
Q:
In 1994, a book titled Managing Clinical Practice
in Critical Care Nursing was written. Are there any plans for an updated version
of this series or other management publications?
A:
Unfortunately, there are no plans to update this
particular series. However, you may find a newer generation of books, some of
which are listed below, helpful.
It's All About You: A Blueprint for
Influencing Practice (AACN)
Acute and critical care nurses can use this
blueprint as a development tool to communicate, to educate and to identify
strategies that affect nurses' professional growth, enhance their collaborative
skills, deal with difficult situations and effect change.
Item #120635
Price: $10 ($12 nonmembers)
Staffing Blueprint: Constructing Your
Staffing Solutions (J. Medina)
This comprehensive resource addresses
staffing issues. The blueprint emphasizes patient-focused care and can be used
to assess your own knowledge, plan collaboration interventions, evaluate the
effectiveness of your plan and assist you in becoming a knowledgeable resource
in solving staffing problems.
Item #300117
Price: $26 ($35 nonmembers)
Standards for Acute and Critical Care
Nursing, 3rd Ed. (J. Medina)
The newly revised Standards for Acute and
Critical Care Nursing Practice describes the practice of the nurse who cares for
an acutely or critically ill patient. The measurement criteria, which detail how
nurses meet each standard, were evaluated and revised to reflect the unique
aspects of acute and critical care nursing practice.
Item #130300
Price: $20 ($25 nonmembers)
Clinical Delegation Skills (R.I. Hansten,
M.J. Washburn)
This book presents many new facts,
strategies supported by recent research and skill-building tools. It is ideal
for anyone who deals directly with the clinical delegation process.
Item #120904
Price: $55 ($57.95 nonmembers)
To order any of these resources, visit
AACN's Bookstore online or call (800) 899-2226. The print Resource Catalog also
lists audio tapes or CDs of presentations at NTIs, which can be purchased
through National Nursing Network. To request a print catalog, call (800)
899-2226.
Critical Care Patient and Family
Guide Is Now Available in Spanish
For Those Who Wait: A Guide to Critical
Care for Patients, Families and Friends is now available in Spanish. Titled Para
Aquellos que Esperan: Una Guia Pura Pacientes en Cuidados Intensivos Sus
Familias y Amigos, this 24-page guide focuses on admission through discharge,
including visiting the patient and the need for a family spokesperson. It
reviews the critical care team, advance directives and possible equipment used
in the critical care unit. This product is appropriate for pediatric and adult
ICU patients and families and provides a helpful glossary in easy-to-understand
terms.
Publication of the Spanish-language guide,
which has been endorsed by the National Association of Hispanic Nurses, was
financed in part by an educational grant from Wyeth Pharmaceuticals.
To order, call (800) 899-2226 or visit the
AACN online Bookstore at www.aacn.org. Request Product # 120638. Price is $1.50
($1.75 nonmembers). Quantity discounts are available.
Public Policy Update
Congress Approves Smallpox Compensation
Congress has approved a package of payments
for people injured by the smallpox vaccine, a move praised by healthcare unions
and those hoping to move the stalled inoculation program forward. Under the
bipartisan agreement, people disabled by the vaccine could get up to $50,000 per
year in lost wages, which is significantly more than the Bush administration
proposed.
Officials hope that establishing payments
for those injured by the vaccine will encourage more people to be vaccinated.
The agreement was negotiated between Sen. Edward Kennedy (D-Mass.) and White
House Chief of Staff Andrew Card.
Under the legislation:
� Families of people who are killed by the
vaccine and die without dependents are entitled to a lump sum payment of
$262,100, an amount based on an existing compensation program for police and
firefighters.
� Estates of those who are killed and have
dependents could choose the lump sum payment or up to $50,000 per year to make
up for the deceased's lost wages. The payments would continue until the victim's
youngest child reached age 18.
� Those who are totally and permanently
disabled would get up to $50,000 per year for lost wages until age 65, with no
cap.
� Those who are permanently but not totally
disabled and those with temporary disability would get lost wages up to a
maximum of $262,100.
Informed Consent Changes Urged for
Critical Care Patients
Critically ill patients often aren't asked
permission before undergoing potentially risky invasive procedures, according to
a recent study published in the Journal of the American Medical Association.
Such procedures frequently are viewed as emergencies, and doctors have little
time to get permission from patients who might be incapacitated or from
hard-to-reach relatives, the University of Chicago researchers said.
They found a simple solution: a permission
form given to patients or relatives when they enter an ICU instead of minutes
before a procedure is done. The form lists eight invasive procedures commonly
performed in such units, including the insertion of breathing tubes and
catheters, and spinal fluid collection. The form also included explanations of
risks and benefits, both key in obtaining informed consent. Using the forms
nearly doubled the rate of obtaining informed consent at the university's adult
hospital, said researcher Jesse Hall, the university's chief of pulmonary and
critical care medicine. The study appeared in Vol. 289, No. 15, April 16.
Report Cites Effect of Working
Conditions
The Agency for Healthcare Research and
Quality has released the summary of a report titled The Effect of Health Care
Working Conditions on Patient Safety. Produced by AHRQ's Oregon Health & Science
University Evidence-based Practice Center, the report concludes that the
evidence is sufficient to make recommendations on specific strategies for
improving patient safety, including increasing nurse staffing levels in
acute-care hospitals and enhancing systems for communicating between hospitals
and other healthcare settings. However, the report also identifies several other
specific working conditions for further research. Among the patient safety
research projects being funded by AHRQ are several to address some of the issues
cited in the report.
FY04 Budget Moves Through Congress
Vice President Dick Cheney cast the
deciding vote as the Senate voted 51-50 to approve a $2.2 trillion FY04 budget
(S. Con. Res. 23). The plan includes the $400 billion over 10 years that
President Bush requested for Medicare reform, including a prescription drug
benefit. The resolution would fund domestic security as well as the drug
benefit. The same day, the House passed its FY04 resolution, which also includes
$400 billion for Medicare reform.
Meanwhile, both the Senate and House have
voted to pass a $79 billion FY03 supplemental appropriations bill, which funds
the war with Iraq and homeland security issues. The bill includes $16 million
for studies on severe acute respiratory syndrome (SARS); $42 million for
compensating those injured by smallpox vaccinations; and $100 million for the
implementation of the civilian smallpox vaccination program. Officials said they
hope the new smallpox vaccine compensation fund will increase vaccination rates.
4-Year Degree Mandate Removed in North
Dakota
After nearly two decades, North Dakota's
requirement that all registered nurses have bachelor's degrees has disappeared.
With passage by the North Dakota Senate of House Bill 1245, the state fully
retreated from its solitary place in nursing education standards. Although other
states were expected to follow North Dakota when its 1985 Legislature passed the
law, none did. Critics charged that it exacerbated the nursing shortage, because
graduates of three-year RN programs in other states could not practice there.
The North Dakota Legislature weakened the
four-year-degree requirement two years ago when it allowed the transitional
licensing of out-of-state RN graduates. The practical effect was that no one
needed the four-year degree to practice in the state, except North Dakotans. The
bill ensures that the state Board of Nursing has the authority to approve all
nursing education programs offered in the state.
Pain Care Policy Act Introduced
U.S. Rep. Mike Rogers (R-Mich.) has
introduced legislation (H.R.1863) to recognize pain as a priority health problem
in the United States. The National Pain Care Policy Act calls for the
establishment of a National Center for Pain and Palliative Care Research at the
National Institutes of Health and the development of six regional pain research
centers throughout the country. The legislation would provide for a White House
Conference on Pain Care, education and training programs for healthcare
professionals, and the development and implementation of a national outreach and
awareness campaign to educate consumers. It would also require development and
implementation of a pain care initiative in all military healthcare facilities
and pain care standards in military health plans and Medicare+Choice plans.
AACN's Strategic Plan reflects objectives
to address priority issues related to providing optimal palliative and
end-of-life care.
New Medical Privacy Rules in Effect
Patients will have the right to view and,
in certain cases, restrict the sharing of their personal health information as
the first federal safeguards for medical records take effect. Millions of
doctors, hospitals, health plans and others must comply with the medical privacy
rules, which cover a broad range of practices, though they are not as strong as
some patient advocates had hoped.
The rules require providers to give
patients a notice detailing how their information will be used. Patients will
have rights to view and copy their records, and to request corrections to
errors. Most "nonroutine" disclosures, such as giving information about an
employee to an employer, will be forbidden without the patient's permission.
In addition, smaller steps will be made to
keep as much information as possible confidential. For example, sign-in sheets
in doctors' offices should not display patients' medical problems, the
Department of Health and Human Services advises. "These new federal health
privacy regulations set a national floor of privacy protections that will
reassure patients that their medical records are kept confidential," said Health
and Human Services Secretary Tommy Thompson.
States may require even stronger
protections. The federal rules were issued by former President Bill Clinton
shortly before he left office in January 2001. Although the Bush administration
agreed to implement them, changes were made that critics said significantly
weakened the protections. The Bush version removed a mandate that providers
obtain patients' consent for disclosing information for purposes of treatment,
payment and other healthcare operations. Officials said that could have
interfered with medical care. They instead required notification of
information-sharing practices.
A coalition of consumers and healthcare
providers have challenged the rules in court, saying the lack of a consent
requirement actually results in broader access to patients' files for insurers,
law enforcement and others. Patients cannot sue over violations under the rules,
but can file complaints with the government, which can impose penalties.
Healthcare providers, many of whom
complained that the rules would be costly and burdensome, have had two years to
prepare. Consultants have advised everyone from large hospitals to nursing homes
and small town clinics on how to comply.
Public Policy Snapshot
Healthcare Reform
� 61% of Americans say the healthcare
system needs fundamental changes.
� 25% of Americans say the healthcare
system needs to be completely rebuilt.
� 12% of Americans say minor changes are
needed.
� Although reforming the healthcare system
is a priority in public opinion surveys, issues such as fighting terrorism,
improving the economy, improving education and schools, and protecting Social
Security rank higher.
Source: ABC News/Washington Post
Public Policy Information Online
The Center for Nursing Advocacy
The Center for Nursing Advocacy seeks to
increase public understanding of the central, front-line role nurses play in
modern healthcare. The focus of the center is to promote more accurate, balanced
and frequent media portrayals of nurses and increase the media's use of nurses
as expert sources.
Stateline Healthcare News
This site is operated by the Pew Center on
the States, a research organization administered by the University of Richmond,
and funded by The Pew Charitable Trusts.Stateline.org was founded in order to
help journalists, policy makers and engaged citizens become better informed
about innovative public policies.
The Latest on SARS
Scientists Identify Cause of Outbreak
� Dutch scientists have produced the final
pieces of evidence needed to conclusively link the microbe, known as a
coronavirus, to severe acute respiratory syndrome (SARS), scientists at the
United Nations body concluded.
� The Centers for Disease Control and
Prevention continues to work with state and local health departments, the World
Health Organization and other partners to investigate cases of SARS.
� As of April 30, a total of 289 SARS cases
among U.S. residents had been reported to the CDC from 38 states, of which 233
(81%) were classified as suspect SARS, and 56 (19%) were classified as probable
SARS (more severe illnesses characterized by the presence of pneumonia or acute
respiratory distress syndrome). Of the 56 probable SARS patients, 37 (66%) were
hospitalized, and two (4%) required mechanical ventilation. One patient (2%) was
a healthcare worker who provided care to a SARS patient, and one (2%) was a
household contact of a SARS patient. The remaining 54 (96%) probable SARS
patients (including the six patients with positive SARS-CoV laboratory results)
had traveled to mainland China; Hong Kong Special Administrative Region, China;
Singapore; Hanoi, Vietnam; or Toronto, Canada.
� As of April 30, the SARS outbreak control
strategy for the United States had included issuance of travel alerts and
advisories and distribution of health alert notices to travelers arriving from
areas with SARS to facilitate early identification of imported cases. Current
travel alerts and advisories can be found at www.cdc.gov/ncidod/sars/travel.htm.
� Healthcare workers have been identified
as a primary "at risk" group for exposure to SARS. Caring for and treating
persons with SARS exposes individuals to infectious droplets. Possible ways SARS
can be transmitted include touching people's skin or objects contaminated with
infectious droplets, then touching your own eyes, nose or mouth or through
airborne inhalation of aerosolized droplets.
For general information about SARS, visit
www.cdc.gov/ncidod/sars. For a list of updated CDC Infection Control Guidelines,
go to
http://www.cdc.gov/ncidod/sars/ic.htm.
Research and Creative Solutions
Abstracts Invited for NTI 2004
Sept. 1 is the deadline to submit research
and creative solutions abstracts for AACN's 2004 National Teaching Institute and
Critical Care Exposition May 15 through 20 in Orlando, Fla.
Guidelines and resources are now available
online. The application will be available in July.
Online Quick Poll
Should beta blocking agents be avoided in
heart failure?
No 72%
Yes 28%
ECCO Users Share Successes in
Integrating Critical Care Program
E-Learning Approach Maximizes
Flexibility
Launched less than one year ago, AACN's
electronic Essentials of Critical Care Orientation has attracted increasing
attention as healthcare institutions across the country implement the
Internet-based program. And, last month's National Teaching Institute and
Critical Care Exposition in San Antonio, Texas, was a great place to find out
more.
For example, representatives from the
University of Kentucky and Rush-Presbyterian-St. Luke's Medical Center in
Illinois shared their experiences with the program in a session titled
"Successfully Integrating E-Learning With Critical Care Nursing Education."
According to Susan Huerta, RN, MS, director
of nursing systems at Rush, the decision was made two-and-a-half years ago to
reintroduce clinical nurse specialists throughout the hospital to focus
primarily on staff development in specific, unit-based clinical areas. Once the
critical care CNS positions were filled, the group began to re-envision how they
might offer orientation.
The goal was to equip nurses to provide
safe, effective and competent patient care. Each specialized ICU concentrates on
its specific educational requirements during formal orientation. Education would
then continue beyond this specified knowledge and accompanying skill sets as a
way of extending nurse development.
"A patient with a head injury today can
have multisystem failure tomorrow," Huerta said. "The nature of critically ill
people is that anything can happen. A patient can really go beyond the
presenting problem, and we want to be sure our nurses are fully prepared.
"With the ECCO program, when a person is
ready to progress to the next level of content, they move on," she added.
Rush has traditionally offered a formal
critical care orientation course four times a year in a classroom setting.
Flexibility became a key component of restructuring the orientation process.
"We desired flexibility rather than being
locked into standard courses that could not be as individualized. With the ECCO
program, we can be flexible in terms of when we offer the course and we can
tailor the education to meet each individual nurse's needs," Huerta explained.
Consistency and standardization of
information and training across the various critical care areas were also
important to Rush.
"The CNSs articulated common competencies
across critical care areas, then we matched these with the different modules
within the program. Since all new critical care nurses will go through the
entire program during their first year, we can be sure that they will have
received the same theory in the same format," said Huerta. This goes a long way
to ensuring a common standard of care."
Nancy Silva, RN, MS, clinical nurse
specialist for surgical intensive care and postanesthesia recovery, agreed.
"The fact that the content is up to date is
a benefit for us. Literature changes take time to publish. You usually have to
wait for the next edition," she said. "Having everything online means changes
can be quickly posted to the program and our nurses benefit from up-to-date
content."
Silva explained that new nurses appreciate
having concrete literature to draw on both during and after the orientation
process.
"I think participants have an increased
comfort level knowing that they'll have access to the structured content once
their orientation is complete. This ability to review the information provides
support to the new nurses as they begin to work with patients," said Silva.
Huerta shared that the decision to
implement the ECCO program came after evaluating the program in terms of meeting
the educational needs articulated through the re-envisioning process, while
simultaneously scrutinizing the resource commitment required versus the benefits
to be gained.
"We determined the breadth of content would
be useful for achieving our goal of consistent orientation in a variable
environment," she said. "The program enabled us to define and articulate the
modules to be completed for each unit and couple this with the skill sets to be
demonstrated in the clinical arena for a usual customary assignment for that
unit. We could then determine how to build the next sets of skills so that, at
the end of a year, we would have an expert nurse."
Like many hospitals, the staff at Rush
works unique hours, with staggered, 12-hour shifts.
"One of the benefits of using this program
is we don't have to ask nurses to come back to work on a day off or to stay
awake all day after working all night to participate in an orientation class,"
said Huerta. "Since it can be accessed 24/7, nurses can progress through the
assigned modules in snippets, sitting for 30 minutes to one hour, whenever they
have time."
Silva added: "We give them time to complete
the courses at work, but they always know they can spend extra time with the
content at home if they want to."
She said the nurses also know that the
instructor can review their progress to determine if someone is having
difficulty with the content or needs to take a test more than once before
getting a passing grade.
"This is a useful tool for keeping us
informed," said Silva.
Huerta also shared a couple of program
features that she particularly liked.
"The breath sounds in the pulmonary module
were fairly realistic, even to the point of one being hard to catch," said
Huerta.
She also liked the fact that doctors'
orders were inherent within the patient presentation section of cases.
According to Silva, the first group of
nurses to use the program did not exhibit apprehension about using an online
education program.
"New grads are familiar with the character
of education and technology, so they did not think it unusual that the program
was computer driven." Huerta said, noting that computer-based learning will
likely be the wave of the future, Rush has made a concerted effort to provide
technology training for all their nurses to make sure they're comfortable with
computers.
About Rush
Rush-Presbyterian-St. Luke's Medical Center
is an academic medical center that encompasses the 824-bed Presbyterian-St.
Luke's Hospital (including Rush Children's Hospital), the 110-bed Johnston R.
Bowman Health Center and Rush University. The Rush Institutes bring together
patient care and research to address major health problems, including arthritis
and orthopedic disorders, cancer, heart disease, mental illness, neurological
disorders and diseases associated with aging. In June 2002, Rush became the 51st
medical center in the country to earn the prestigious Magnet Award for
excellence in nursing services, the highest honor awarded by the American Nurses
Association.
Who Is Using ECCO?
California � Naval Medical Center San Diego
� Regional Health Occupations Resource
Center-Butte College
� Stanford University Hospital
� Sutter Coast Hospital
Colorado � Memorial Hospital Colorado
Springs
Florida � Broward Community College
� Lee Memorial Health System
� Department of Veterans Affairs Medical
Center, Miami
� Department of Veterans Affairs Medical
Center,
West Palm Beach
� Mercy Hospital (Miami)
Illinois � Rush-Presbyterian-St. Luke's
Medical Center
� Sherman Hospital
� Scott Air Force Base (375th Medical
Group)
Indiana � Department of Veterans Affairs
Medical Center, Indianapolis
Kentucky � University of Kentucky
Maine � Maine General Medical Center
Maryland � Suburban Hospital
Massachusetts � Good Samaritan Medical
Center
Minnesota � Allina Hospitals & Clinics
Missouri � CoxHealth System
Montana � Benefis Healthcare
� Frances Mahon Deaconness Hospitals
Nebraska � Good Samaritan Health System
New Hampshire � Mary Hitchcock Memorial
Hospital
New Jersey � Atlantic City Medical Center
New York � Champlain Valley Physician
Hospital
� St. Mary's Hospital (Seton Health)
Ohio � Department of Veterans Affairs
Medical Center, Cincinnati
Oregon � Oregon Health and Science
University
Pennsylvania � Dubois Regional Medical
Center
Texas � Denton Regional Medical Center
� Harris Methodist Fort Worth
� Presbyterian Hospital
� University Hospital
� Hendrick Medical Center
� Southwest Texas Methodist Hospital
Utah � HCA-St. Mark's Hospital
Virginia � Bon Secours Memorial Regional
Medical Center
� Martha Jefferson Hospital
� Northern Virginia Community College
Washington � Capital Medical Center
� Kadlec Medical Center
� Northwest MedStar
� Sacred Heart Medical Center
� Sunnyside Community Hospital
� Northwest Workforce Development Council
� Yakima Valley Memorial Hospital
West Virginia � Princeton Community
Hospital
Wyoming � Campbell County Memorial Hospital
Canada � Queen Elizabeth II Hospital, Grand
Prairie, Alberta
Japan � U.S. Naval Hospital, Yokosuka,
Japan
Sepsis Education Program Available
Eli Lilly Grant Underwrites Purchase Fee
for CD-ROM
Identification and Management of the
Patient With Severe Sepsis," AACN's national sepsis education program for
nurses, is now available in a self-paced CD-ROM format. Funded by an
unrestricted educational grant from Eli Lilly and Company, this program is
sponsored by AACN and is accredited for 5.0 contact hours of CE credit for
single users.
Narrated by clinical expert Barbara McLean,
RN, MN, CCRN, CCNS-NP, FCCM, the new program offers clinicians a comprehensive
view of the latest information on the diagnosis and care of patients with severe
sepsis.
The 170-page, audio/slide CD-ROM study
guide includes pathophysiology of severe sepsis; identification of acute organ
system dysfunction; antibiotics, source control and monitoring in severe sepsis,
including investigational and new approved therapies; hemodynamic, ventilatory,
renal and other aspects of care; and nursing care of patients with severe
sepsis. Case studies are also included in the presentation.
To order this cutting-edge learning program
for only the $7.50 shipping and handling fee, call (800) 899-2226 and request
Item #004060. Quantities are limited.
|
