Before I started my nurse practitioner program I was happy
where I was in regards to my health. I was at a great weight, my diet had been
free of any processed sugars and grains, and I was working out several times a
By the time I started clinicals in my primary care site I
felt like a hypocrite. I had not been to see my PCP in 2 years, my gyn in 3,
but I was up-to-date on my dental visits! My diet was filled with on-the-go bad
choices, my full time job was now a work at home position, the gym was a foreign
place and my weight was creeping up and up and up.
I am a determined person. I have completed 3 marathons, a
half marathon and countless 5Ks but time was against any motivation that I had.
There clearly were not enough hours in the day.
So each day that I was telling people how to make healthy
lifestyle changes, reduce their stress and take hold of preventative medicine,
I felt like I was definitely not practicing what I was preaching. Even so, I
sold it with determination and many patients were making wonderful changes.
Now that I work in urgent care, 95% of the time I feel less
like I have to worry about being in disguise. I do however spend 5 hours a week
in primary care and therefore again began having feelings of guilt. I decided
to get off of my high horse and make some dreaded appointments.
Off to the lab for yearly blood work, appointment set for my
yearly gyn exam and appointment made to discuss blood work and have a physical.
I understand that no one truly likes having to go in for these routine
appointments. I dread the discussion about my increase in weight and what my
thoughts are about this.
I truly try to make my patients' experiences with me in
primary care a positive experience. I have compassion for schedules, costs and
decisions that are made around healthcare. I will be the first to admit that I
am proud of my patients who follow through.
I had a patient who had not been to the PCP in 3 years. She
too was worried that she would be berated about her obesity and was quite
anxious about this. We had a wonderful discussion about her life in general and
her goals and whether they were realistic or not. I encouraged her to make her
appointment with her GYN, her mammogram and of course sent her for her blood
work. When I called her to let her know she was severely Vitamin D deficient
and how we would work on correcting it, she excitingly told me that evening she
was off to have her mammogram completed and that her GYN appointment was
scheduled. I felt like a proud parent and praised her for her follow through.
My primary care preceptor in school was amazing. She took
the time to talk with her patients in a comforting and holistic manner. She
spent her lunch hour eating while returning patient phone calls which I found
to be truly dedicated. In the end you saw the results in patients who followed
through and came to their appointments.
I understand that practices are busy and that this may not
be productive for many but am curious to know how many of you are in primary
care and call your patients? Do you find that this is adjunct in your care of
your patients or do you find that this opens up other issues?
"Thank you" is one phrase that can change the outlook of your day. Last week while at work the office manager came up to my co practitioner and me. In her hands she held a letter from a patient, thanking the office for the great care that she received. The office manager eagerly asked us to see who saw her and I was surprised to find out that it was me.
I remember the patient well: An elderly patient who lives at home alone with a history of fragile, thin, aging skin. She tripped on the corner of her area rug at home and fell into a door jam, lacerating her forearm. I had briefly met her during my orientation period as she was having previous sutures removed.
Her current laceration was complicated - it had several flaps, was a bit jagged and of course was surrounded by friable skin. I spoke with her, letting her know that I would try as best as I could to put the wound edges back together again but that I was unsure it if would be completely possible. I needed to take my time as any major tugging of the sutures risked pulling right through the skin.
Because of this we had the opportunity to strike up a nice conversation as I placed her thirteen sutures. We talked about the New England weather, her life and family, and how she was enjoying her retirement. In the end the wound came together nicely and we parted ways.
It was nice to know that she appreciated the time and care that I gave. Most of the time I am lucky to hear patients say thank you at the end of their visit. It just feels plain good. I try and pay that same gratitude when I am out and about in the community, often just saying "I appreciate your time," whether I am at the doctor's office or paying for groceries.
Work has continued to go well. We are seeing an influx of positive flu patients and those that have been battling long winded respiratory infections. I am starting to see repeat patients which has also been quite enjoyable.
We had our first provider meeting that included the new PA and I received a lot of positive feedback. We discussed the new coding requirements for ear irrigation and the upcoming deadline to become certified to do DOT physicals. Needless to say it is a class I will be taking in March and yet another computerized certification exam to complete. I really thought I would have a break from that for a little while!!
According to the DOT guidelines, "By May 21, 2014, all certified medical examiners must be on the National Registry database, and drivers must obtain a medical examination from a certified examiner."
After that certification I will start looking for future conferences to attend. Will there be an NP Boot camp? Perhaps a national association's yearly conference? The choices are endless!
In our urgent care there are four full time providers: three
physician assistants and myself. Our medical director, a physician, comes in
one half shift per week. As we enter a patient's room, we always introduce
ourselves by our title. "Hi, I'm Katrin and I am a nurse practitioner." There
is never any bait or switch and patients are aware of who we are right from the
beginning. Even so, I am referred to as a doctor on a daily basis. I always try
and clarify my role, but for some patients t is just habit to call you doc.
For me, it is not anything that offends me. I understand
that the role of the nurse practitioner may be a new concept for some. We are
lucky, though, that the role is present more and more not only in the primary
care offices but also in many specialty areas. Having nurse practitioners and
physician assistants in these offices often allows patients to be seen in a timelier
manner. Other nurse practitioners may take offense not being addressed by their
I have taken it a little more to heart and have decided to
apply to my graduate school's DNP program. I knew that at some point in my career
I wanted to take the plunge, I just was not sure as to when. Because of the
amount of days that I have off per week I feel like this is the best time to do
so. So although I will not be an MD, I will one day be Dr. Moskowitz.
I am officially off of orientation at work and becoming
accustomed to the increased work load. Two of us providers hold down the fort
and we are seeing the winter illnesses such as influenza and sinusitis flow in.
I have found that although I was not able to perform many procedures in the
emergency room since I was an RN, I did pick up many tricks of the trades along
This past weekend my coworker had a patient with a
dislocated toe and she asked for my opinion and guidance. When she was unable
to relocate the toe she asked if I would take a look and give it a try. I was
able to relocate the toe and when asked how I knew what to do, I just smiled
and thought of all the wonderful doctors in the ER who were willing to have a
curious nurse in the room during procedures.
Every Tuesday morning I work in the director's primary care
office covering his patients. This is a nice change to my week but comes with
its own difficulties at times. While I can handle the sick visits without
difficulties, I sometimes find it difficult to complete follow ups. I look
forward to maybe one day being able to increase my hours in primary care and
building up my own patient load and following my own patients from beginning to
My entire life, relationships have always been a struggle. Growing
up as a child of the Army I learned to go into defense mode when it came to
friendships. You knew that as soon as you became BFFs with another kid, someone
was about to move to another state or country.
My entire career in medicine has been built around short-term patient
relationships. In the ER you may have several hours with a patient, but more
often than not they are in and out. Urgent care has been the same story with
even shorter time frames. Yes, you do see some patients again, but they are not
coming in for long term care. Now that I am a practitioner I focus on making
the time I have with my patient the most pleasant and memorable, hoping that if
they need me in the future they will come based on their past experience.
When I spent 6 months in my primary care clinical I saw a
completely different side to patient care: longer relationships between the
provider and patient. I have to say it was a nice change. I was able to see how
patients trusted my preceptor and how the preceptor was truly able to
incorporate the holistic care model.
It was not just about the medical problem but also involved asking
about home life, work and other happenings. It felt less like an informal
office visit and more like a caring one on one conversation with the added
benefit of a physical exam.
I wonder if I am at a point of my life that I want extended
relationships in my career. It was definitely a consideration as I looked
towards where to settle as an APRN. I now have the opportunity to work part
time in a primary care office in my own community. It would allow me to build
up a patient load and follow them and build those relationships. It is in the
early works but something that would allow me to dip my feet in the waters
before jumping straight in.
As we start off 2014 I want to think less about resolutions and
more about redefinition. I hope to continue to develop as a practitioner and
truly take in anything and everything that I can that will allow me to continue
to provide consistent and compassionate care. I also want to redefine my own
health and happiness within myself in order to be able to relay that same
feeling towards my patients. I encourage you to think about how you want to
“redefine you in 2014”.
The last month has been a whirlwind. Each and every shift
has provided me the opportunity to put my didactic lessons into play.
Delegating has made my life easier and knowing what everyone in the office can
and cannot do is immensely helpful.
The patient population has been good. Most patients are
receptive and willing to listen to what you have to say. That is not to say
that there are not those who you know will be non-compliant with your plan of
care (and those who will tell you that outright).
In this setting we are afforded the ability to see patients
for a recheck or call them on the phone for follow up and it is always
reassuring to hear that patients are feeling better. There is definite
appreciation to hear your practitioner's voice on the phone telling you that
your labs are negative or positive or just saying "How are you feeling!" My
preceptor in primary care made it a point to talk to her patients and return
phone calls and I know that this was part of why patients loved her and felt
connected with her as a practitioner.
While my transition has been going smoothly there are still
areas that need continual development. My greatest challenge right now is x-ray
interpretation. Granted, if there are obvious fractures I feel great and
confident, however chest x-rays are still my downfall. They all seem to look
the same. I am in search of a good website or book that will help me see the
normal norms compared to mildly abnormal and then obvious abnormals. If you
have one, please comment!
Procedures come and go on a daily basis. I have completed my
first major I&D and although not my favorite compared to suturing, it is
oddly satisfying to clear them all out of their purulence.
The largest thing that I have had to get used to is the fact
that I have so many days off! Years of working 68 hours a week, while going to
school full time was something that I was used to. Now that I only work 7 days
out of my 14 day template, it is odd to actually have days off to do things.
I have started thinking about returning to school for my
DNP. There have been a lot of discussions in regards to the transition and the
requirement of NPs to receive their DNP. For me, it was always a desire to
continue on; the question remained as to when I would go back.
My school offered a direct entry into their DNP program for
current students but I felt I wanted to get a little time under my belt before
I jumped in. Plus I was starting to resent writing papers and reading books so
I needed an educational hiatus. Next fall however, I feel that I am destined to
get back to school. My husband always joked that I would become an MD but I
know that a doctorate prepared NP will be the life for me!
Throughout life we build our own individual skill sets.
Often times we are our own guinea pig and learn from our own mistakes. Often
times however, if we build skill sets based on our careers these trial and
errors often affect others.
During nursing school I remember being overwhelmed by the
amount of new procedures that I was being taught. Granted, we had the aide of
models that provided the perfectly accessible orifices, but eventually we had
to perform those procedures on live and anatomically varying people.
Over the past 6 years as an ER nurse I can say that I became
pretty proficient at certain things; IV starts, foleys, colostomy appliances, code
medications, etc. Nurse practitioner school definitely built on these skill
sets but also added new elements.
I had always listened to the heart, but now I was doing it
more thoroughly and diagnostically. I had to become comfortable with more
intimate exams including rectal exams, pelvic exams and prostate exams to name
a few. During our clinical intensive we lacerated and sutured cow tongues and
lanced our homemade lotion abscesses, but my clinical rotations did not afford
me the ability to practice those on live individuals.
Starting off the bat in urgent care I knew that procedures
would be a daily occurrence and to be honest I was looking forward to this. I
was honest during my interview to let them know that I had no experience in
things like digital blocks, suturing or I&Ds on real patients. Show me and
then give me the chance to try it on my own, and I would more than likely
I have learned that you have to be confident in your
perceived ability to perform a task. Without that internal cheerleader, you
often are defeated before you even start. I have seen so many procedures during
my nursing career that I inadvertently engrained some great tips and tricks
into my brain.
A lovely patient became one of my firsts. He had the
unfortunate luck of stepping on a piece of glass while traversing his kitchen
barefoot. In his heel he felt that there was something there bothering him with
each step he took. An x-ray did not show with foreign body but palpation of the
heel elicited a nice pain response. Off I went to numb my first appendage and
go looking for a normally invisible item.
It did not help that he had attempted himself to find said
piece of glass leaving a pitted heel to guess which hole might hold that glassy
treasure. Off I went. Infiltrating a heel with a needle was a little more
difficult than I had anticipated but after that ordeal was accomplished I was
ready to go.
I had seen another ER provider at one time use an 18G needle
to explore a wound first to see if they could come across the change in
texture. Sure enough this worked and I was able to manipulate the glass out
without having to use a scalpel to cut into his heel. I have to say I was
pretty proud of myself and I did end up telling my patient that he was my first
in this endeavor.
Since then I have placed my first sutures, successfully
irrigated cerumen impacted ears, hand expressed abscesses, removed sutures and
seen my first complicated patients who are like those proverbial Pandora boxes.
Each and every day has been a learning experience. I have
learned that I could suture all day long. As I said to my husband, "It is like
arts and crafts on people," putting them back together again. I look forward to
being able to add new files into my file cabinet of skills and of course share
them to all of you!
surprise, all of my licenses arrived the Friday before my projected start date
of November 11. Here is an updated timeline of all of my paperwork endeavors:
09/24 Passed school's comprehensive
exam and officially graduated
09/25 Passed boards
10/11 Submitted Ct license
application and hospital credentialing packet
10/30 Received Ct APRN license,
applied for Ct Controlled Drug License and NPI number
11/2 Approved for Ct Controlled Drug
License, Applied for DEA license
11/7 NPI number received
11/8 DEA license received in mail
Unfortunately, I was informed that
my employer had not received back my malpractice certificate. Therefore I would
not be able to start on Monday. I was assured that it would be "soon", but no
definitive date could be given.
To say that I was disappointed was a
true understatement. I had to take a different approach and just believe that
it would all happen when it was the right time. The call to start came Tuesday
afternoon while I was busying myself with household tasks. I was to report to
human resources in the morning and start my official journey.
Day 1: I spent
my morning taking care of the business portion of employment. I received my
badge, filled out my direct deposit forms and then went on for some computer
training. Lastly I met the vice president of the hospital to talk about my new
membership as part of the medical staff. I then headed over to my group's
administrative office and completed fire and OSHA training.
After lunch I was able to head over
to the urgent care clinic and meet the staff and tour the facility. The staff
was very warm and welcoming and my primary preceptor was eager to show me the
ways of the computer system.
Day 2: "Time to
see some patients" is the greeting I received when I walked into the door
Thursday morning. I was ready, or was I? I started nice and slow. The hardest
part for me was navigating a new computer system. I am technically savvy, but I
felt clumsy and unorganized in my charting.
My mind also was stuck in clinical
mode. I felt the need to report back on each patient that I saw. My preceptor
reminded me "you are the practitioner now." Oh yeah! I am! It all really did
not sink in until I had to handwrite out a prescription, with my name and my
signature. "That's right, I am allowed to do this now!"
It has been difficult to shift my
mindset and understand my new role, and I am sure that overtime this will
improve and hopefully with it will come a bit more confidence. Later in the
afternoon I was also able to meet the other new provider who is a new graduate physician
assistant. I knew that we would be orienting together and I was selfishly glad
that I would have someone to talk to during this time who knew and could relate
to the difficulties I was having.
Day 3: More
computer training. Very helpful to become familiar with the program that will
help you through the busy times! In the afternoon I spent more time at urgent
care meeting new practitioners, a drug rep and receiving my official schedule.
I have a set date of independence of Christmas Day. What a present that will
be! Trying to learn the lay of the land, one patient at a time, but also tying
in all of this to find that inner NP that is waiting to burst out of her seams!
The last few weeks have been a harsh lesson in patience and
letting go. I am the type of person who likes to be in charge of my own fate
and like to have clear deadlines and goals. While applying for the various
licenses and staff privileges that are necessary in order for me to start work,
I have also needed a lesson in how to trust the process, be patient and know
(or at least have faith) that things will fall into place.
I know that there are a lot of questions in regard to how
quickly various entities take to process applications so I wanted to give you a
recap of where I currently stand. Please note that these vary depending on the
state that you live in.
Passed school's comprehensive exam and officially graduated
Submitted Ct license application and hospital credentialing packet
Received Ct APRN license, applied for Ct Controlled Drug License and NPI number
Approved for Ct Controlled Drug License, Applied for DEA license
I am currently projected to start work on November 11, but
that is dependent on receiving medical staff privileges through the hospital
and this will not happen until my DEA license is received. I am having a hard
time living in limbo.
I have heard that the processing for the DEA license can be
as quick as a few days all the way to the projected time of four to six weeks
per the DEA website. I am reminded that I am pretty fortunate at the above
timeline as I have a classmate whose state of Illinois is just now processing
applications received in August. I did hear from the hospital's HR department
to verify vital statistic information so that is one step further into the
Now I need to shift the focus on getting back into shape.
Before school, I had dropped my weight down through healthy dietary changes and
many Crossfit workouts. I felt great and also knew that I could set a positive
example to the individuals that I would be caring for.
During the 6 months of clinicals, this all went down the
drain with a decrease in the available time to work out and heading back to "on
the run" eating habits. My new schedule will allow me to work out a bit more,
but I also want to work on getting back to running on a regular basis. I look
forward to having a healthy outlet!
In the meantime I continue to wait, think positive thoughts
and cross all of my fingers and toes for a Monday start date!
All required packets have been submitted to their respective
entities. My immune system has been prepped with a TDAP booster, influenza vaccine
and PPD administration. Drug screen was completed and now I have to do what I
do not do best: wait.
To keep my mind busy I have been cranking out the hours in
the ER as an RN and have also been researching ways to keep myself ready for NP
action. Although I am performing nursing tasks, I always do my assessment and
think, "What would my NP alter ego do?" I am very fortunate to work with other
practitioners who I can clarify why they chose certain treatment paths without
worry of feeling sublevel.
There are many different nurse practitioner educational
programs available, so I know that clinical experiences can vary and with that,
differences in the ability to develop certain skill sets such as suturing, 12
lead EKG interpretation, digital blocks, etc.
For some, these might be skills that they would prefer not to
have to complete, but for me, they are things that will keep my day varied and
exciting. I have looked at some adjunctive courses to enhance these skills, but
with them come a bit of a cost factor. Again, I am fortunate enough to have an
understanding employer that knows that I am still developing these skills and
will hopefully have a good preceptor who will show me the ropes. I have looked
into obtaining the following additional resources for practice:
Stat 12 lead EKG tool
I would love to hear what resources you have used to help
get you through your practice!
I have also had the opportunity to think about my long-term
future and further educational goals. There is a definite push of NPs
completing their doctorate. I had thought at first that I would jump right into
the DNP program right at the finish of my MSN, but I am currently education-ed
out. I need a hiatus after spending the last 9 years straight in school. Once I
feel like I have settled into practice, there is also a definite desire to do
some sort of teaching. And this is why I chose to become a family nurse
practitioner! So many options out there in the world.
I look forward to finally posting about patient care, the
lessons I get to learn and the transition into my new workplace. Until then
life still seems pretty much like it always has!
Greetings from the happiest place on earth: Disney World.
When I planned this trip months ago it was meant to be a celebration trip and
thank you to my family for sticking through the last 2 years of NP school.
In my mind I would have passed my school's comprehensive exam and the national
boards. Just a few weeks ago I panicked, again thinking in my head about the
possibilities of failure in either or both of those upcoming feats. Everyone
around me had no worries, telling me that they had no doubt that I would pass.
They, however, did not just cram 2 years' worth of various knowledge bases
throughout multiple lifespans into their heads. The more I reviewed materials,
the more I felt like I maybe had not retained all that I should have. Self-doubt
is a devious creature.
I scheduled my exit exam for the earliest available date I
could and was able to schedule my boards the day after. Why would I do that? I
just needed to get it done and over with. It was 2 days of acid producing,
nausea-filled days and sleepless nights.
Exam one was scheduled at 9am with an 8:45 a.m. check-in
time. I arrived early to park in the correct parking garage and walked to my
respective testing center. No one was there. Office closed and doors locked.
I spent the next hour waiting and then having to make my
way back to my car to retrieve my phone and figure out what to do. Needless to
say it did not aid in my already elevated anxiety and once tags were
straightened out, I was worried that taking the exam might not be such a good
Instead, I pushed through and passed my comprehensive
again. Phew. The next day was a different story. The new testing center was not
only open, but organized and ready to receive me. In fact, entering the exam
was like entering prison: Empty your pockets, turn them inside out, lift up
your pant legs, turn around, hands in your pockets.
My anxiety was in control until I sat down and saw what I
was doing there. AANP National Boards. I put on my lawn mower-looking provided
earphones and dove in. At the end of the exam, before they release if you
passed or failed, they ask you to answer a brief survey. Bad bad idea. In those
10 questions I felt my heart rate skyrocket and all I could click was strongly
agree, strongly agree until I saw the final words: PASSED. I could have cried
at that moment. Instead, I let out a huge sigh of relief and slowly headed to
The fact that I passed everything has still not sunk in.
Even after filling out malpractice paperwork for my new job and signing APRN as
my title. Now I just need to wait and pray that all of the licensing agencies
act hastily. Now I can relax, enjoy vacation and prepare to enter the workforce
in my new role!
While I await my boards I have been compiling all of the
necessary papers that are needed for purposes of licensing. With this also
comes making a list of all of the fees that come with this. Although I will be
receiving CME funds at the beginning of the year, my initial applications will
all come out of pocket for me. Ready for the list?
Connecticut APRN License Application: $200
Connecticut Controlled Drug License Application:
DEA Number Application: $730 (ouch)
Hospital Credentialing fee: $200
NPI Application: FREE!
So all of this money is out before I even start work! If you
have the opportunity to set aside money now, please do so. With all of these
applications comes the waiting game. Once boards are completed I have to wait
for the official notice from AANP in order to apply for my CT NP license. My
license can take 1-2 months. I cannot apply for anything else until I have my
license in hand. Did I mention I am not very good at waiting? Time to pick up
some extra shifts in the ER as an RN as I wait and save to pay for all of these
I did receive my final employment contract to sign. I am in
no way well-versed in contracts and the interpretation of them. They are
however a staple in the world of the NP as I have learned. I have had to sit
down and, section by section, figure out what the next two years of my life will
Depending on the setting and who the NP ends up working for,
these contracts I am sure can run from simple to super detailed. I did find
certain aspects of coverage very interesting. For instance: your obligations
upon finishing a contract, getting out of contract and of course salary and
benefits. Don't ever be afraid to clarify items or even have the contract
Next order of business? Application for hospital privileges.
Because I will be working for a hospital affiliated physicians group I have to
be credentialed through the hospital. Enter paper packet number two. They
really should have told us in school that applying for everything feels like
signing mortgage paperwork; it is endless and overwhelming to say the least! I
currently have a start date at my job of November 11, 2013. Although it seems
so far away, I know that it is necessary in order to complete all of the above.
Until then I am continuing to study, study, study. The more
I do the more I feel as though I have so much more to learn! I have self-doubt
and nervous energy because so much is riding on this! Then I go into NP mode!
If I were my patient what would I do? Perhaps a PPI for my acquired GERD?
Perhaps an anti-anxiety medication, one that does not cause sedation? Or maybe
just good old fashioned sleep and deep breathing! In the end I just need to trust
in myself and know that what will be, will be.
As I sit here to compose my first blog post as a new
graduate, I am feeling a bit bittersweet. The last two years have been long,
adventurous, overwhelming and exciting all at the same time. Now it is time to
regroup and make my post-graduation plans.
This past weekend I attended a board review class and as I
sat there, I realized that things are getting real. Just six months ago I was
worrying about transitioning into clinicals and making sure that I was
following all of those evidence-based guidelines. Now I am working on studying
for my school's exit exam and of course my boards so that I can start work as a
family nurse practitioner. I am feeling some definite PTSD from when I
graduated nursing school and was preparing for my NCLEX exam. What if I don't
I am fortunate to have the added pressure of having a job
waiting for me as soon as I have my NP license in hand. It is a great position
in a freestanding urgent care center that is part of a hospital's
multispecialty physicians group.
The fortunate part of this position is that I will be
replacing a physician assistant who is not leaving until December. This allows
for me to have an extended orientation and transitional period into my new
role. This was something that was very high on my priority list of my first
job. The last thing I wanted was to be thrown out into a new role, hoping that
things would fall into place.
I will be doing all the normal colds and coughs, but will
also be able to perform office procedures, interpret X-rays and EKGs and spend
half of a day a week in a primary care setting. Ultimately, it is the best of
both worlds for me. I also will be working twelve hour shifts during the week
and every other weekend, affording me the ability to have days off during the
week to attend to doctors appointment and school activities.
For any new graduate who is interviewing for a position,
please make sure you go in prepared. I was fortunate to have had a great
regional clinical faculty who sent me some great questions to ask during my
interview. Some of these included:
- Are there productivity incentives? (The more patients you see or
the more services you bill for, the more money you get?)
- Does urgent care have appointments or is it a walk-in only?
- How would you learn procedural skills such as I&Ds, suturing,
- How many other NPs/PAs are there in the department? (This will
tell you if they are used to working with us.)
- Will you ever be alone (even on weekends) or will there always be
someone there with you?
- Do most of the patients you see have a PCP or is it likely they
will have to return to the urgent care for follow-up?
- Do you have electronic health records?
During the interviewing process I
learned that most entities work with contracts. These are very detailed and
full of jargon that I had never been exposed to before. I was able to get a
draft copy and review this over and over again in the comfort of my own home
and then make a secondary list to review with the administration of the group. Don't
make such an important decision without having time to do this.
This next year promises to be an
exciting one for sure. I hope to learn many new lessons that I can share with
my fellow new NPs or NPs to be. Only we know how hard we have worked to be
where we are today.
I had my first jaw dropping patient last week. You know, working
in cardiology, you see a lot of the same thing. Acute coronary syndrome, atrial
fib, heart failure...Turn 'em and burn 'em, that's my motto. Thursday, I had my
first patient that I was completely side-bombed over.
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
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
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
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
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
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.
So I've written about cases the last couple of times and I'm
thinking it's time to give you guys an update. I've been in my position as NP
in an acute care setting seeing cardiology patients for 3 months now. I can't
believe it! It's going really well and I'm really grateful that this
opportunity was given to me. I've learned so much already and I learn so much
more every day.
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!
In our acute care setting, we deal with death and dying on a
daily basis. It truly amazes me, the differences in between patients' reactions
when facing a "death sentence." I'm sure this can be noted in all walks of the
healthcare system, as well, but it's by far been most noticeable to me in the
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
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.
Why the difference in the patients' reactions? Does
Mrs. A. have dealings with family or friends that need to be taken care of to
put her at ease? Is Mr. G. comfortable with his idea of the afterlife, whatever
it may be? I guess we'll never know what the true reasons are for the
difference in these patients' responses to diagnoses of terminal illnesses.
All we can do is try to live our lives to the fullest and know where we are in
hopes that once it's our turn, we will be at peace with ourselves.