What Makes For A Good Orientation
Briana Juskowiak Briana Juskowiak

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.

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Clinical Pearls: Shock
Briana Juskowiak Briana Juskowiak

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.

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Job Options For AGACNP Nurse Practitioners
Briana Juskowiak Briana Juskowiak

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.

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Clinical Pearls:What’s up with the lactate?
Briana Juskowiak Briana Juskowiak

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.

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Provider Decision Fatigue
Briana Juskowiak Briana Juskowiak

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.

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Mentors: Game Changers?
Briana Juskowiak Briana Juskowiak

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.

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When Should You Start Job Applications
Briana Juskowiak Briana Juskowiak

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.

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Clinical Pearls: DIC
Briana Juskowiak Briana Juskowiak

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.

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Nurse Practitioner Boards Preparation
Briana Juskowiak Briana Juskowiak

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

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Clinical Pearls: Liver Failure
Briana Juskowiak Briana Juskowiak

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.

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Mistakes To Avoid On Your Resume
Briana Juskowiak Briana Juskowiak

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.

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Clinical Pearls: Evaluating For Intubation
Briana Juskowiak Briana Juskowiak

Clinical Pearls: Evaluating For Intubation

When is it time to say it’s time? I think back on the really bad days of the pandemic when I walked from room to room asking myself this question repeatedly. Honestly, for intensive care unit level covid that’s what it felt like - a few random meds that typically didn’t help, supportive care, and careful vigilance for when it was time to go on the dreaded vent. Our patients feared it, our families feared it; it was the elephant in the room every time you walked in. Outside of covid pneumonia, there are a million reasons why a patient needs mechanical vent support and failing lungs are just one component. This is a very common question I get asked when I am training a nurse practitioner student Here’s how I approach evaluating a patient for intubation need.

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NP vs RN: Differences in employment structure
Briana Juskowiak Briana Juskowiak

NP vs RN: Differences in employment structure



This topic comes from a question I received from a client asking to explain how nurse practitioners fit into a physician run group. She expressed her surprise to learn that many APPs and physicians who work in a hospital are not employed by the hospital and asked for feedback about how this works and how nurse practitioners fit into this model. I definitely understand this confusion. As nurses, we are used to standard hospital or health system employment with clear hierarchical management. In this post I’ll talk about my experience with this and the main differences between NPs and RNs in regards to:

Who employs you.

Who manages/directs you.

How you get paid.

Who your colleagues are.

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Toxic Workplaces And What to Do About Them
Briana Juskowiak Briana Juskowiak

Toxic Workplaces And What to Do About Them

I talk to a fair amount of nurse practitioners who are in a space of indecision. My goal is to help them sort out what will best serve their {whole} life goals. It’s always about balancing work-life factors with career goals. Some of them are considering leaving the profession and going back to the bedside or doing something else altogether. Some are coming to me seeking interview/job acquisition help and what we discover is that their confidence has been wrecked by a unhealthy work environment. I’d be willing to bet many of you have experienced this in the past or are stuck in this situation currently. It’s truly a sad state of affairs these days particularly for nurse practitioners. In this article I wanted to talk about this phenomenon and what some options may be for you.

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Clinical Pearls: Pressor Selection
Briana Juskowiak Briana Juskowiak

Clinical Pearls: Pressor Selection

The foundation of critical care practice stands upon heart and lung support. As you know a multitude of problems lead to these downstream complications, but at its core what we do in the unit is handle worst case scenarios. Even for a new nurse practitioner with loads of years at the ICU bedside, pressor selection can be difficult at first. What I hear from students is “Levo, let’s just start Levo.” They say this because it has been their experience and it’s of course discussed everywhere. But when I ask them to defend the selection there can be a dearth of knowledge. Ultimately, they may be right, but I argue that as a competent provider one must have a good understanding of the pharmacodynamics of the drug AND the pathophysiology of the disorder you are treating. Why? Because while the physician/team you are practicing with currently may never question you, at some point you will need to explain your rationale. And on a baser level you need to accurately treat the problem or you could 1)chose something ineffective 2)make things worse or 3)harm the patient. Let’s talk vasopressors.

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Nurse Practitioner Fellowships
Briana Juskowiak Briana Juskowiak

Nurse Practitioner Fellowships

When I say fellowship, I’m really referring to two types of post-graduate training: nurse practitioner residency and nurse practitioner fellowship. What’s the difference? A residency is more general and encompasses a broader scope of practice. It may be a longer time frame as well, most range between 6-12 months. It is ideal for someone who had little bedside experience or sub-par education in school (be it academic or clinical). A fellowship on the other hand is specialized and has a particular focus of interest. It is ideal for someone who has a strong sense of what they want to do and/or lack the opportunity to find a way into the niche.

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Clinical Pearls: Waveform Capnography
Nurse practitioner Briana Juskowiak Nurse practitioner Briana Juskowiak

Clinical Pearls: Waveform Capnography

End tidal carbon dioxide (ETCO2) measures exhaled carbon dioxide, it therefore reflects the efficacy with which CO2 is pumped back to the lungs (indirect measurement of cardiac output) and then exhaled (ventilation). Waveform Capnography is a continuous tracing, or waveform, of ETCO2. It is very useful when assessed as a trend.

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The Best Nurse Practitioner Podcasts
nurse practitioner Briana Juskowiak nurse practitioner Briana Juskowiak

The Best Nurse Practitioner Podcasts

Are you an avid auditory learner? I’m slightly obsessed with podcasts. I tend to go on benders based on what is going on in my life. I listened exclusively to travel podcasts for eighteen months when I planned a European trip a few years ago. I have always liked to use podcasts as an adjunct to my professional education as a nurse practitioner. IMO it’s hard to utilize them exclusively just because the search functions are not as robust (there’s a lot to dig through to find one talk about a subject like normal labs, etc) and the content is long. But, once you find a quality show that addresses your specific population it’s great to listen to on a more regular basis (versus a search approach). The nuggets of wisdom you can garner from these discussions can greatly impact your practice. You may have to be willing to wait for them, but if you were going to be doing the dishes anyway, why not multi-task? In this post I will share my favorite podcasts (which are mostly ICU): what I love about them and how I use the info in my career as an ICU nurse practitioner.

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Clinical Pearls: Pleural Effusions
Briana Juskowiak Briana Juskowiak

Clinical Pearls: Pleural Effusions

Pleural effusions can be a big barrier to improving respiratory status in the ICU. Deciding how and when to treat them becomes easier once you break down how to diagnose and treat.

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