Clinical Pearls: Ventilator Modes 101
There are a number of reasons why ventilators are confusing, and I’ll break down how to simplify these factors in this blog post. But the big takeaway is this: just because a patient seems controlled well on the vent does not mean he is; do not leave the task of interpreting the vent and the patient’s response to the vent to others. It is incumbent on you to educate yourself about what the knobs, numbers, and waveforms mean in order to better treat your patient. Let’s talk vent basics and it starts with understanding the mode.
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.
Job Options For AGACNP Nurse Practitioners
It is a common occurrence that NPs who I talk with personally or read about in forums indicate they do not understand the possible roles they can serve as an adult gero acute care nurse practitioner. Most people see that certification and think “I don’t want to be an ICU NP; not choosing that path.” The purpose of this article is to highlight the many, many different pathways you can take with your AGACNP certification. Obviously, being an acute care NP I possess some bias, especially given my personal job acquisition experience (more on that later). Having disclosed that, I do want to add that I speak with around 50 NPs a year who represent primarily FNP and ACNP certifications and am aware of the national trends in hiring. Trust me when I say, I’d be willing to bet there are far more possibilities out there for you as an ACNP than you realize.
Clinical Pearls: Is It Time To Extubate, An Objective Approach
I spent a lot of years working at the bedside in the ICU. I can tell you one thing a nurse won’t tolerate and that’s an agitated and intubated patient. IYKYK. It’s scary, it’s physically taxing for you, and it’s not good for the patient. So naturally I would immediately call the provider with the “can we extubate” query when they woke up fighting. In my mind they were awake, right? Let’s liberate them from the ventilator!
This is only one scenario in which the clarity I gained in NP school blew my mind at how naive I was as a nurse. Maybe naive isn’t the right word, uninformed perhaps? IDK, I think my point is I didn’t realize there was a systematic approach to assessing extubation readiness. I didn’t properly think through all the reasons why a person would need a vent, nor appreciate all the ways in which a person can fail an extubation attempt. One key factor I learned is that objective medical analysis of the diagnosis and current exam is crucial in predicting risk and then weighing the risk/benefit ratio to determine what is safest for the patient. In this post I’ll walk you through the step by step process of performing this assessment to eliminate as much doubt as possible and set your patient up for success. Skip to the end for a bedside checklist.
What To Look For In An NP School
A simple google search for your desired nurse practitioner program will yield multiple pages of results. Starting with paid ads. Some seem legit, some seem sketch. So you go to FB forums only to see mixed results and lots of heated online arguments. So you ask people you know at the hospital, turns out they all go to the same one or two in your area that maybe doesn’t fit your needs. You do some deep introspection and honestly aren’t sure what you need anyways. Why is there no objective checklist out there in the world? Some tool that allows for school comparison and advice about what to choose? This is the blog for you my friend. In this discussion I’’ll give you the big list of variables to consider.
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.
Provider Decision Fatigue
One of the best perks about leaving bedside was the reduced physical strains. No more tired back and aching knees. No more needing to sleep for a solid day following a stretch of work shifts. That was the expectation at least. The universe quickly let me know how mistaken I was. Not because of aches and pains, but mental exhaustion. The day after work stretches were still demanding of recuperation but for very different reasons now. I would race through each work day, moving from one set of problems to the next, trying to outrun the fear of making a mistake. It was exhausting. And after I left for the day, the endless rehashing of all the hard choices I made and the associated burden left me in a hazy state of indecision for even basic life decisions. Chicken or fish? Can the youngest go for a sleepover tonight? Should I shower or just go straight to bed??? The inability to make rational decisions after a long day at the hospital (especially in the beginning) was unexpected. It’s something I talk to training and new NPs about a lot, because in my mind, if you are aware of it you will experience less isolation and imposter syndrome. In this post I’ll talk about what it is, why it’s so bad in this new role as a nurse practitioner, and what you can do about it.
Clinical Pearls: Weird COPD Labs
I recall sitting in my ninth grade biology class and feeling awed at how perfectly our bodies are designed. It is infinitely complex at baseline - just keeping the status quo. True magic happens when badness ensues and the body begins to change it’s patterns to compensate. Must. Keep. Things. Going. It’s amazing to me. That’s the moment I knew I would go into the healthcare field.
To this day I remind myself that just because modern medicine offers the capability to tweak things, sometimes the best thing we can do is just stay out of the way. First, do no harm. It’s tough though, because when things are hitting the fan, the instinct is to look at a set of patient problems and try to optimize them. If you fail to recognize when an abnormal finding is actual a new normal in a chronically abnormal person you may jump to fix things, unintentionally worsening things. That’s a heavy use of the noun things, but you get what I’m putting down right?
COPD is a perfect example of this phenomenon so in this post I will discuss the normally abnormal derangement’s that can occur in a patient with COPD. Why they occur, how to interpret them, when to intervene, and when to leave them alone.
Mentors: Game Changers?
What is the most insightful thing someone ever told you? When I try to narrow down my answer to this I struggle. I lost my mom when I was twenty four years old. It was traumatizing and also character building. She was my mentor in all ways and without her presence I have struggled in my life, particularly with making hard decisions. Thankfully I have had some career-guiding, life-changing people come into my life at exactly the right moments. The story I share most often is in regards to deciding to go back for a masters degree. A friend of my moms (who happened to be a nurse at the hospital where I worked) said “Briana, what’s your hangup?” I told her the big issue was the burden I would put my husband and children through for two straight years. Especially the girls who wouldn’t see as much of me. Her response “Honey, two years will pass whether you are in school or not, where do you want to be in two years? And what will teach your girls more, being present for all the events or role modeling how hard things are done?”
Okay universe, I hear ya.
In this post I will discuss the difference between a mentor and a coach, what they can offer you, how to find one, and how to make the most of your time.
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.
When Should You Start Job Applications
January…the month following December graduation. It’s a joyous time, and you absolutely should be celebrating. But what comes next? What I see across the nurse practitioner forums and social media are two big concerns: board exams and job acquisition. I wrote about board certification and how to prep for this a few weeks ago; today I’d like to focus on a topic that I think half the people are getting wrong. That is timing for job application. Many NP students ask when is the right time and the responses are mixed. On a recent post I tallied it was completely split 50/50. Half the people felt you should apply while in school and half felt you should wait until exam and licensing is complete. My argument is that if you are waiting until the latter you are behind the eight ball. Statistically speaking, I know this is likely to stress out half of you and that is not my goal. Hear me out, there are many reasons why I advocate for earlier efforts. Let’s talk about job applications.
Clinical Pearls: DIC
One of the rare and weird things in medicine that combine a dramatic constellation of opposites. Caring for someone in the throes of badness from two dichotomous problems leaves one in a state of floundering. Do I treat the clotting or do I treat the bleeding? What will kill them first? It’s universally known that getting the diagnosis of disseminated intravascular coagulation is a dreaded event. DIC is a downstream complication that arises late in the game with several diagnoses that we see in the ICU, and unfortunately in our maternal population. Every time an OB calls our team to see or transfer a patient to ICU my shoulders instantly feel tense. Let’s talk about the pathophysiology behind this dreaded state and what our treatment options really are.
Nurse Practitioner Boards Preparation
After one has achieved the degree, put in the herculean effort to study, stressed beyond reason, hyper-fixated on all the possible outcomes, and then stood in this place of last minute test anxiety, bargaining with one’s maker is where you may find yourself. Based on the conversations I have with NP students I precept and online / via my mentoring business, I can confidently say only a tiny fraction of new grads are immune to this fear. There are some things out of our control as a neophyte, but boards preparation is not one of them. Taking control of how you ready yourself for this exam definitely impacts anxiety level as well as success rate. In this post I will discuss the best way to prepare for your nurse practitioner board certification exam
Clinical Pearls: Liver Failure
Oh the ways the liver can fail. As a new nurse practitioner this one was hard to get down. Cardiology is generally seen as the bee all end all when it comes to keeping our bodies running, but I’d like to talk about the under appreciated liver. Hepatology is fascinating because the normal function of the liver is supremely multi-faceted. Throw in a little pathology and any number of pathways can be deranged and within those any degree of severity can be seen. From acute to chronic to acute-on-chronic, severity can run the gamut. Decompensated cirrhosis is a common killer in most ICU’s. Given how poorly understood this disease state is, I’d like to talk about the complexity, progression, prognosis, and management of liver failure in the intensive care unit.
Mistakes To Avoid On Your Resume
I’ve seen a fair number of nurse practitioner resumes in my day. Seems like my large group is always cycling through new hires. In addition to that I look at all the resumes that come through for my consultation/interview prep business. It’s interesting to me the variety of what folks are doing across the nation. When I wrote my first NP resume I assumed we all heard the same HR lecture and wrote them the same. Most people have professional looking resumes but there are some industry specific issues that I find am repeatedly addressing with clients. In this post I’ll discuss the most common mistakes I see on the nurse practitioner resume.