That day, an 86-year-old female presented to the ED for shortness of breath. She's admitted to the hospitalist service. Labs are drawn and the patient has a BNP of over 2000. She arrives to the floor and a cardiology consult is placed. I quickly make my way to the room to do the consult and when I initially begin to talk with the patient, everything seems to be "normal." Then the story unravels.

The patient has been diagnosed with diastolic heart failure for years. She's never had a true exacerbation. She saw her cardiologist in September for her annual follow up. At that time, the patient had generalized complaints of a minor increase in shortness of breath, but there were no medication changes instituted at that time.

In December, the patient was having more shortness of breath and also began to feel quite fatigued. Her husband had begun to notice some physical changes indicating she was retaining fluid. They decided at that time to see her primary care physician, who drew a complete blood count on the patient.

She was severely anemic with a hemoglobin of just over seven. Since there were no obvious signs of bleeding, he set the patient up for an upper and lower endoscopy. No GI consult; just set up the procedure. They both were insignificant so the physician ordered five transfusions over the next 4 weeks and then left it at that. No follow up on it.

Let's fast forward about 4 months and get back to me interviewing this patient and her husband. She is clearly uncomfortable while she is just lying in bed. They tell me that she's progressively become more swollen over the last 4 months but they don't know how much weight she's gained because they don't have a scale.

About 3 weeks ago, the patient became extremely fatigued and was requiring a moderate amount of assistance with her activities of daily living and for the last week, it was absolutely complete assistance with everything. She couldn't move at all.

At this point, I've done my questioning of the patient and her husband and I was still thinking this wasn't too crazy of a case. And then comes my physical exam and where my jaw drops. I proceed with my cardiac exam and realize that there is 1+ pitting edema where I place my stethoscope on her chest to listen to her heart sounds, and mind you, I'm not pressing hard at all.

I have her husband assist me in getting her rolled over because at this point, even just lifting her arms was a difficult movement for her. We finally get her rolled over and the poor patient had pitting 3+ edema to her scapula. This folks, is the perfect picture of, yes, anasarca. 

She had 3+ pitting edema down her entire body. I couldn't get pulses in her lower extremities. Her upper and lower extremities were cool to touch and had a decrease in sensation.

So after I finish my exam, I talk to the husband a little bit longer and then go to the dictation room with chart in hand. I managed to find her cardiology clinic chart and start delving. This patient has managed to have CHF for this long and has truly not had an exacerbation.

Please remember we live in Northern Michigan. There is a great percentage of our population that is not highly educated. Unfortunately, the socio-economic gap that exists has a huge impact on many of our patients truly understanding their diagnoses and the lifestyles changes that need to be enacted to ensure that they don't become exacerbated. And this patient is the prime example of that.

They were not able to tell me the first thing about heart failure. And this isn't at the fault of their outside providers. It's simply because they just couldn't wrap their heads around the information when it was given.

You know that form that you do as a floor nurse asking a patient what is the best way that they learn? You know. One of the many that you just click boxes without really even asking the patient. This is one of the most important questions that need to be asked. We need to know how to teach our patients, or, to pound it (for lack of a more appropriate term) into our patient's heads.

I went into her chart to assess what medical therapy she was on and what tests had thus far been ordered. I called the echo tech to find out the "unofficial" results of her echo and was informed that they were unable to do the test. They tried but the patient's excessive fluid level did not allow for the ultrasound to be able to visualize the cardiac structures appropriately. We had to wait.

The lasix drip had been going for a couple of hours (why the heck a lasix drip, I don't know; don't get me started on that) and so now we were at that time that I like to phrase "hurry up and wait." (Military background. Can't help it.) So I made changes to her oral medications to ensure she was on the most appropriate therapy for her heart failure, which is much more detailed than I remember when I worked in a cardiac stepdown unit.

When I went in Friday morning, the patient looked better. She was actually sitting up on the side of the bed. She needed some assistance but not as much as she had been and she had diuresed about 2 liters. So we continued that process over the weekend.

We had a newer hospitalist on service on Monday and I met up with him to discuss the case. The patient had been severely anemic since December and had come in to us anemic. She had continued to drop and over the weekend, this had not been covered.

He said that this was chronic and I let him know that I was concerned because the numbers didn't lead me to believe that it was an anemia of chronic disease and that it had truly been worked up. He told me to focus on the heart. Nice. Then he told me he wanted to discharge her, but was going to wait one more day. Another jaw drop. She had diuresed over the weekend but she still had 2-3+ pitting edema to her lower back and was still really weak. I told him I thought that was being a little aggressive.

I guess my input went unheard. I had class the next morning and when I rolled in after lunch, I learned that my patient had been discharged. Yep. Discharged. I couldn't believe it. I spoke with the cardiologist that I worked with and he said that he told him he thought it was a little early, but the guy discharged her anyway.

So I did what I do best. Got fired up and started making calls. I called the primary care office, the cardiologist's office and our heart failure clinic. I got appointments set up and then I called the patient. I talked to her husband and told him the importance of remembering what we talked about. Remember to limit her fluids, and watch her salt intake and go to her appointments. 

Now all I can do is sit back and pray that she makes it to her appointment in 4 days. Pray that she doesn't end up back in the hospital and pray that she is safe at home with her weakness. Not many patients really get into my heart but for some reason, this one did. It's patients like her that make me realize why I do what I do. To be the advocate for patients who just don't get it.

I've had my ups and downs with administration with the adjustment of trying to maintain my family life and work life. It's slowly coming together and things are looking more positive every day. I truly love the colleagues that I'm working with and the doctors. They are all extremely supportive in regards to patience and teaching, and for that I'm truly thankful.

I think one of the biggest challenges that I've emotionally faced is having the feeling of distrust from the "older" nursing service. I feel like I truly developed a positive rapport with the floor nurses and I believe that they understand that I'm new but that I work my butt off make the best decisions that I can for the patients. They also like the fact that I was a floor nurse and I'm sorry, but once a nurse, always a nurse!

There will never be a day that I won't empty a urinal or take a patient's old lunch tray away. Where I've met challenges is with some of the higher-up nursing staff. I understand that I'm in a position that has great effects on their patient population. I get that they don't know me from Sam Jones and so there is that distrust there.

I just have an issue with the way that it's handles sometimes. Tone...That means a world of difference, you know? The way that you speak to someone will either make them want to listen to you, support you and respect you, or it will make them shut down.

That's where I'm at at this point. It's tough. I'm the new guy on the block. I get it. Don't run me off. You know why? You'll just end up with someone else new on the block and starting all over again. It's one thing I never, ever understood about the nursing community. Why do we "eat our young?" We should support them and teach them. They are the future! We are the future! We need to work together to support and encourage one another. That is truly the way to ensure the best possible healthcare is given to our patients.

So I'm off to another hectic week! It's been crazy, crazy and it's not even summer yet! Hope you guys are having a great week. Please give me some ideas on topics that you'd like to delve into. It makes for a more interactive environment, which in my opinion is always a good thing!

Take Mr. G, for example. He's 67 and had just been told that he has metastatic cancer and that he has approximately 4 weeks to live. Prior to this devastating diagnosis, he had been in what he thought was good health. He had never been admitted to a hospital and led what he believed to be an active and healthy lifestyle.

Now take Mrs. A. Mrs. A is 83 and had just been told that she has a very short time left, due to her heart failure progressing so much that she was continuously going into atrial fibrillation.

Both of these patients had been told they have terminal illnesses. Now here's the difference that gets me. Mr. G. is at peace with his diagnosis with his family surrounding him. He states that he's ready to go whenever it's his time and that he's just going to continue to live his life to the fullest.

Mrs. A. on the other hand, is an emotional mess. She is devastated and has no one around her besides her providers to lean on. She says that she isn't ready to die. She's been a physical disaster with her health for the last 5 years and is constantly uncomfortable because of her heart failure. She, however, isn't ready to pass.

The really amusing thing? I opened the mail a couple of weeks ago when my license came through and it's a little piece of paper that said I was a nurse practitioner. Didn't say adult NP. Didn't say a specialty in gerontology. Nothing. Just "NP." Same effect when my certificate came from AANP. Generic. Not fancy. My husband said, "So that's what $30K bought us, huh?" It was quite amusing actually.

A friend commented that her teaching certificate was more fancy. Makes me chuckle. When you look on paper, that's it. But in real life, it's amazing. It's more than a piece of paper. It's a life change. It's a position change. It's the most important piece of paper I've ever had, and I love it! The way that I feel every day when I go to work is what I paid for. Loving this job and loving the patients I'm helping to stabilize in this setting is what I paid $30K for.

I had requested statistics from my fellow classmates on certification and how many had passed, how many had jobs, were licensed, etc. I didn't have a very big response. Not sure why exactly, but I can tell you that I had responses on the prolonged times that it takes for EVERYTHING! Once you finally get your date for boards, it takes about 4 to 6 weeks to get the official response in the mail. Then you have to get that sent to the state and submit your application for your license. That, in itself, takes 6 to 8 weeks. I'm hearing from classmates that it takes that much time or longer for being credentialed! Add the time spent in finding a job if you haven't already? Well, you can pretty much guarantee that you're going to be working about 3 months after graduation, at minimum. I'm working, but with lots and lots of red tape! Until NEXT WEEK!!! Then bring it on baby!

Now? I realize... Let's see... In my first three weeks, I've gotten snowed in at my house (couldn't get down my hill) and my kids have been sick twice. And then I get the call that I was needed in management's office. I was sat down and asked if everything was ok. They are concerned because I've missed so much time and questioned if I really feel "committed to the team." This killed me. I felt absolutely TERRIBLE about having to call in and then to be questioned about my commitment was the straw on the camel's back.

I LOVE this job. I love the people that I work with and I love everything about the institution. To have this questioned was disheartening. I can totally understand where they're coming from, though. They don't know me from Joe Blow and I'm calling in right off the bat. I've hired a nanny but she's only available on Mondays, Wednesdays, and Fridays so of course the kids have to be sick on Tuesdays and Thursdays, right? That's really the only thing that makes sense.

I think my biggest issue is the strong feeling that I'm the crappiest mother in the world. All I really want to do is stay home and take care of my babies when they're sick. We're seeing such a huge increase in viral cases that are having devastating endings at work and that just adds to my increasing anxiety about nurturing my little ones.

The practitioner in me knows it's probably "just a virus," but the mommy in me is yelling that my baby is sick and it might be worse than we all think. All I want to do is cuddle him all day and let him know that his mommy is right here and loves him more than anything in the world!

And then reality sets in. The mortgage has to be paid, the utilities are best when kept on and no one's happy if there's not food on the shelves. So off I go to work to tend to those sicker than sick in the hospital and pray for my sick little one at home.

He was sent down the next day for a Cardiolyte stress test to work-up the cause of the a-fib. This is where things get difficult. You send your patient down for a scheduled test and then get a stat call to the area, where you find him being resuscitated. WHAT?! What the heck?! He's coded for close to an hour in Nuclear Medicine, while en route to the cath lab and actually in the cath lab.

The doc does his damnedest to figure out why this patient is still not having any type of rhythm while he is still being coded. I've never seen a team work so well together trying to save a life. In the end, it's not all candy and roses. We don't save everyone. Life isn't the easiest. He was the first patient I've truly lost as a nurse practitioner and I promise you that this case is forever etched into my brain.

It comes with the job though. Well, that's what my dad says. And I, as a practitioner, know this. I've coded umpteen patients in my nursing career and I've seen death. I'm not going to say that it doesn't bother me because it's always made me sad, but from my standpoint I believe that death isn't the end so I usually handle it ok. I think that this patient was different for me because of the ties that he had to our facility, his age, his wife's hysterical reaction (which is ENTIRELY understood) and just the fact that it was completely out of the blue!

You just have to tell yourself, or at least I do, that there's a reason for it. None of us know it and we don't understand it, but there is. And then we just have to keep moving on. Keep saving lives. Keep helping patients that are here right now. And remember to keep in mind that we will lose patients, but thankfully we save so many more.

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So I've debated and debated on what my topic for this blog was going to be and I finally figured it out. I have gone from working three 12-hour shifts as a registered nurse to working five 8-hour shifts. Yep. You guessed it. I work banker's hours. Monday-Friday from 8-5.

Sounds nice, huh? Well, you factor in the 1+ hour drive there and another hour home (I live in Northern MI and with all the snow storms, lately it's pushing 2 hours each way) I'm gone from home from at least 7am-6pm. So here's my dilemma and I would LOVE to get feedback from my readers on this! When do you take care of YOU?

I'm getting up at 4 so I can have time to do 30 minutes on the elliptical before I get my two rug rats up and get them ready for school and out the door. I have exactly enough time to do that and barely make it to work on time. I am super OCD and not having time to keep my house clean is making me more stressed out and I feel that I am not able to do my wifely and motherly things that I'm used to doing.

So that's my excuse as to why I'm not exercising and eating the way that I'm used to! What's your excuse, and more importantly, what can WE do to remedy this situation? We are practitioners here! We preach to our patients about the lifestyles that protect our hearts, minds and bodies and then we go to and get McDonald's on our way to or from work and pass out at night after a glass of wine from exhaustion.

Now what does that say for ourselves? I'm really looking for feedback here. This is a great spot to network and get our creative juices flowing so that we can better ourselves, which in turn is going to be beneficial for not only our family, but our patients as well!

Since I'm the blogger, I guess I technically should be the first one to throw out some ideas. Like I said earlier, I'm "kind of" OCD (not technically, but just funny about cluttery areas and germs) and I am, you guessed it, a Virgo. For those of you that don't keep up with that kind of information (well, I don't either. I just know I fit the bill), virgos are very "Type A."

Control freak (raising hand), consistent (raising hand again) and outgoing (Who? Me? Nooo). So one area that is of high importance for me is organization. Since we're on the topic of a lack of time, I have figured out that maintaining organization really helps with an overall increase in my free time. About a year ago I discovered a website called Cozi (you can access it from here:http://www.cozi.com/live-simply?redir=home) that is AMAZING for organizing everything from your schedule to your shopping lists to your recipes! It has an app that you can put lists on and they transfer over automatically to your spouse's phone on their list! That's right! No more excuses about not having the notes!

So, there's my first idea for you guys so that you can give yourself a little extra free time. Now, what do you have for me? I look forward to hearing your responses and I'm REALLY looking forward to sharing my journey ahead in regards to being a new NP!

My morning was fairly uneventful. I did everything you're supposed to do. Got a full night's sleep the night before and woke up in the morning to have a good breakfast. Made it to the testing site and then was told I should have come in 30 minutes early (I could never recall seeing those instructions anywhere).

Needless to say, they were "graciously" able to accommodate me. After sitting in the waiting room for another 30 minutes, they shuffled me back to the area where you are pretty much TSA'd (I find this terminology humorous). I get seated and the first computer was broken. After the lady tried to figure it out for 10 minutes, she gave up and put me at another computer. I get it started and realize that it was giving me 4 hours from my original appointment time of 0900. Yep. That's how it started. I lost an hour right off the top. GREAT!

I could sugarcoat it for all of you soon to be new grads, but I'm not going to. I made pretty good grades in school and felt pretty confident after the predictor exams. Those exams were a joke in comparison to Boards. And hey, maybe I was the lucky one, and just managed to get the 150 most difficult questions out of the 1500 question bank. I do have good luck, you know! It was excruciating.

I was literally crying (not bawling out loud; that's later) when I hit submit and held my breath and prayed like I have never prayed before in my life. It took absolutely FOREVER.

When the screen finally popped up, it was 2 huge paragraphs and I actually had to pull myself together and get my eyes uncrossed to find where it said "PASSED." That's right, people! By the grace of God, I PASSED!!!

Now there's still that nagging voice in the back of my head. You know, the one that's saying, "Well, it said that it was preliminary score (they always say that), so you really could have failed." You know that voice, right? I managed to make it to my car (after some more TSAing) and then I broke down.

I called my husband and I was crying so hard that he thought I had failed. I pulled myself together, somewhat, and told him that I passed, but that was it the most excruciating time of my life. And I still stand by that. EXCRUCIATING. But I passed, and that's that. Now let's move on!

So I'm a new NP! Yep! That's right! I said it! I'm a NP!!! Do you hear me world? Okay... Well... As a new graduate, we're all excited. We've worked so hard over the course of the last several years and it's finally here. It's anticipated and expected. And then? It arrives. I'm not sure if it's just me, but this is how my last year went. January: "I can't believe it. I'm graduating in 12 months!" June: "Ok! 6 more months to go!"  September: "It's never, ever, ever going to get here." November: "Oh my gosh! One more month! Woot woot!" December: "What? It's here? I have to take boards soon? Hold on a minute! Wait! NO! Not yet! I'm not ready!!!" Please tell me that I'm not the only one that felt this way. Right?!

So I graduated on December 15, and boy was it exciting! Scary, yes, but still exciting. The anticipation of boards is killing me and I know that I can't procrastinate forever. I'm anticipating sitting for them the second or third week of January. After much contemplation, AANP is the certifying body I decided to go with, really just due to the fact that, personally, I hate statistics and everything that goes along with it. The thought of being tested on it during boards makes me sick to my stomach.

I'm really and truly looking forward to writing this blog and interacting with my readers! I know that this will be quite the interesting year coming up and me, being the outspoken person that I am, will be quite the "voice" for others that are in the same position I'm in. About a month before graduation, I accepted a position in a hospital and dun dun dun... I have a degree in primary care.

Now don't get on a high horse with me here! I already know the dilemma and I'm fully prepared mentally to head back to school to get certified in acute care. The only reason I feel halfway okay with accepting this position is because of my strong background in critical care and cardiology. I had another opportunity in the primary care setting, but to be honest with you, I just didn't feel the fit. The group I'm going to be working with really feels right to me. You know what I mean? Just a gut instinct.

So for the next year or two, I hope that you will follow my blog about being a new NP and life's trials and tribulations. Please feel free to leave comments and if you want me to broach a topic, just tell me!