What Makes For A Good Orientation
How long is long enough? When will I know I’m ready? How will I learn all this? All valid questions you should be considering when starting your NP job. Especially if this is your first job. The transition to practicing as a nurse practitioner is hugely different than that of becoming a nurse. Not only do you have all the clinical stuff to learn but even the work of learning how to structure your day, how to author notes, how to bill, what needs follow -up. So many facets of just being an NP exist, beyond the medicine piece. This is what many underestimate and these factors just do-pile onto the mountain of overwhelm many feel when becoming a nurse practitioner. So the appropriate question is what will my training be like? In this article I attempt to break down the components I feel lend itself to a good orientation process.
Clinical Pearls: How To Work Up Hypoxia Part 1
I was recently drafting some material for a client who I am tutoring regarding hypoxia. She is in a pulmonary rotation and this is a very common reason for consult. I think when you are providing a consult service (which can receive a high volume of patients) keeping things focused on your organ system, standardizing your approach, and developing automation’s are the key to efficiency. The cool thing is that when you systematically work through the causes of hypoxia you can simplify the process of coming to the most accurate diagnosis. Then you can offer the primary team a suggested plan of action and be the hero (or maybe just uphold your reputation as a trusted colleague 😉). This article is designed to help ease the process of working through the etiology and focuses heavily on pathophysiology. If you can appreciate the pathway of oxygen delivery from the atmosphere all the way through to delivery at the tissue level you can better understand the disease states and more easily come to a diagnosis (or three, as is our common reality).
NP Jobs Red Flags
I know times are tough in the NP job market, but you are more “stuck” in NP roles as opposed to nursing roles so you should do your due diligence when considering your next job. In this article I discuss the big red flags I feel you should look out far in regards to money, people, terms, contract, and the interviewing process. I share the top 3 questions you can ask to illuminate whether those concerns are valid or not.
Clinical Pearls: Shock
Diagnosing the type of shock your patient is exhibiting is clutch when it comes to appropriately treating. Yes, Levophed is our quarterback when it comes to pressor selection, for good reason. But you need to have a darn good understanding of what it can and cannot do, when it is not the ideal choice and when there are better or adjunctive measures that must be undertaken quickly to save your patient. It all starts with coming to an accurate diagnosis. Often in real world practice this is hard to do as multiple states can co-exist, iatrogenic factors obfuscate, and no one piece of data is the be all end all. As with most things in medicine, you have to piece together the data to form the picture. This article reviews the pathophysiology, shares a hemodynamic chart, and overviews how to differentiate shock states.
How To Use Your CME $
I’m writing this blog post as I sit in a hotel in New Orleans. I’m looking out over the Mississippi River and contemplating getting dressed for the early morning lecture or spending this time with you. This won’t be your run of the mill discussion about medical conferences. I intend to share with you the good, the bad, and the ho hum ways a conference can contribute to your knowledge base and suggest the many ways you can utilize this precious resource to elevate your practice.
Tips For Finding A Nurse Practitioner Preceptor
Options with your school start with knowing your rights, what is required of the school, and whom to network within the school. Beyond that there are several resources I suggest you use. There is also a specific approach I suggest you take to improve odds for success. In the end you may find you really have to hunt to find a nurse practitioner preceptor.
Clinical Pearls: Procedures Performed In An ICU
What exactly can I do as an AGACNP working in an ICU? Commonly encountered question with the answer being fairly straight forward, with a little variation. Several factors exist which effect routine practice and this includes your training, your credentials (with the hospital), the comfort level of your attending, and the culture of scope allowance at your specific workplace. I’ve worked places where I do it all, and places where I do less. I find this varies most by work team structure and culture. The more staff available, including medical trainees the fewer procedures you will likely perform. Most students are aware of the common procedures we perform (central lines, dialysis catheters, and arterial lines) but there are a whole host of procedures we could perform. In this article I’ll discuss the myriad technical skills we as nurse practitioners can learn and perform to contribute to patient care.
Clinical Pearls: Calcium Channel Blocker Overdose
Toxic levels of calcium channel blockers typically induce massive cardiogenic and distributive shock and pressors alone often won't save them. High dose insulin therapy enters the chat here. Think 700 units of rapid onset insulin IV per hour 🤯. Yep, it's gonna be an all hands on deck kind of patient my friends. Read this article to learn about the whys, whos, and hows of CCB overdose mgt.
The Worst Parts Of Being An NP
My number one most viewed youtube video is about the downsides to practicing as a nurse practitioner. I guess I shouldn’t be surprised by that. You want to know what the cons are before diving head first into uncharted waters. It’s a great illustration about how life mimics art. My craft is working as a critical care nurse practitioner and informed decision making is a huge piece of making life and death decisions. As long as the patient and family is aware of the risk/benefit and I do my job well in explaining it to them, we can all go forward with realistic expectations. Same should be true about making a big life decision like going back to school. Since very little in life is all good, anticipating the challenges/cons to this career tract is everything. In this blog post I’ll discuss the biggest bummers to daily life as a nurse practitioner. If you are in a season of deciding on nurse practitioner school, this one is for you.
Clinical Pearls: Intubation Starts Here
Beyond practicing the technique of intubating, nurse practitioners should spend time learning to identify the patients at risk of cardiac arrest. If you can put a finger on the major risk, there are definite strategies you can employ to improve odds of success without decline. In this article, I discuss specific approaches to: GIB/vomiting, hypoxia, shock, asthma, and metabolic acidosis.
The Perfect NP Student
If you are a student reading this, you are already in the top 5% my friend. How am I so omniscient you ask? Well, after serving as a preceptor for the last five years or so I’ve seen all sorts of students. We all are unique and bring different skills, backgrounds, and personalities to the learning space. This should be celebrated, the world would be awfully boring if we all were the same. Having said that, there are trends I see amongst nurse practitioner students, and some of them are not so great. I’m going to tell you what IMO I believe makes for a fabulous student in clinical rotations; one we want to hire. Arguably one of the best qualities is beginning with the end in mind. Those who prepare in advance are not amongst the majority, so congratulations for being an elite! Clinicals are your #1 source for job acquisition, so you want to show up with your A game!
Clinical Pearls:What’s up with the lactate?
In 2001 a research article was published expounding early goal directed therapy as a treatment strategy for sepsis. Key points in the article suggest that physical exam findings are subpar for directing resuscitation and that measures such as lactate, SCVO2, base deficit, and pH are more accurate measures of adequate treatment. There were certainly other factors, and the take home message was to find the source and start antibiotics early, but volume resuscitate until tissue hypoxia improves was the practical application of this research. As a result lactic acidosis has become a bad omen to be feared by all. Several guideline updates have since been published, the most recent in 2021 with weak evidence to suggest using lactate as an end-point measurement. Practically speaking though, the word is out that a high lactate = bad bad badness. I’m not saying it isn’t bad, but there are plenty of reasons why an elevated lactate alone is not the end of the world. In this post we’ll discuss causes for lactate elevation, what should be cause for alarm and what shouldn’t, and how to manage it.
Clinical Pearls: VBG vs ABG
There is a legitimate reason why ER providers consistently order a VBG over an ABG and the ICU provider then may or may not believe the VBG choosing to tack on an ABG instead.
Many patients in the hospital require assessment of their acid base balance and oxygenation/ventilation status which is best quantified from serum arterial samples. Additionally, the ABG provides expedited lab results such as hemoglobin, potassium and other electrolytes, and lactic acid. These values are very helpful in making a rapid diagnosis and treatment plan. A venous blood gas seems to be the standard replacement for an arterial blood gas in the emergency department. It does offer some benefits, but has limitations as well which should be acknowledged.
The focus of this article is to describe the pros/cons of using a VBG as a surrogate, the exclusion criteria, and the method of converting a VBG to an ABG.
Clinical Pearls: Is it DKA or HHS?
Should be pretty straight forward, but even amongst seasoned providers this can sometimes be debatable. Especially when you don’t have all the labs back. Often we are called to admit a patient for DKA because they do not seem appropriate for a routine floor or even step-down ICU admission. The Internal Medicine/Hospitalist team may not feel comfortable taking a patient but on your evaluation they do not seem to be on the severe end of the spectrum. You aren’t alone, my friend. Let’s talk about admitting a DKA vs HHS patient and how you make a diagnosis.