mammac5 7,919 Views
Joined Nov 10, '09.
Posts: 735 (30% Liked)
I work in both inpatient and outpatient DM mgmt. There is theoretically no limit to the doses of basal insulin...no upper safe dose to prescribe the way we think of meds like METFORMIN. Having said that, I normally will have pts split a large dose into 2 injection sites for better absorption...say, if they are injecting 80 units total I would have them inject that into two sites, but they can do so at the same time.
Patients who require 200 or more total daily units of insulin may do much better with U-500 insulin since the volume injected is much smaller and seems to be better absorbed/assimilated. I live/practice in an area of the country with high insulin resistance and actually use quite a bit of U-500. We still use NPH for some patients, as well. Especially since it is dirt cheap at Walmart pharmacies...not as great a basal insulin as LANTUS or LEVEMIR (which usually should be dosed BID) but cheap = the only way to go for many patients.
Appropriate to hold the insulin in an elderly patient with CBG of 75 but if your institutional policy says you must notify the prescriber when you judge that the insulin should be held, then you should follow that policy.
Giving the insulin and then offering the patient a milkshake would frustrate the CRAP out of me, as a prescriber! What is the point of that? Why would anyone give a milkshake to a diabetic patient? Sheesh.
Y'all may or may not agree with ChuckE's post, but can we all just agree that it was funny as heck? We have to remember to take nursing (and our responsibilities there) very seriously...but we don't always need to take ourselves quite so seriously.
School matters - particularly for new grads, in my opinion. I was hired at a hospital that is known NOT to hire new grad NPs...even new grad NPs that are already RN employees at the hospital and who have reputations as good nurses and employees. I was offered the job for a couple of reasons (contacts I made in my field during ANP clinicals, solid interviewing skills, etc.) but it was helpful that the physician deciding whether to interview me was familiar with the school I went to and worked with other physicians who did their residency at the same school.
Would I have a job right now if I didn't go to a "big name" school? Maybe so, but it would probably have taken months longer to find something and it wouldn't have been THIS job - which is my dream first job.
As someone who has 66 days until graduation (but who's counting, right?) I can say that the single best piece of advice I can give you is this:
Don't get behind!!!!
Sounds simple, I know, but it can happen very quickly and before you know it you're trying to claw your way out a big old hole you've dug for yourself. Don't let it happen.
Have your calendar ready (one big enough to write lots of things down) and sit down with every syllabus each semester and enter the dates when assignments are due. Then use a highlighter to mark those that are biggies (tests, scholarly papers, etc.) so you can't possibly miss them. Personally I like to make a little square to the left of each calendar entry because I feel strangely satisfied by putting a check in the box for each item I accomplish!
Budget and guard your time. If you're going to work full-time (which no one I know can actually accomplish while also doing 30-hr wk of clinicals) you absolutely must be realistic with your time and expectations. Family & friends must know that you won't have much recreational time during the program and that you will strategically ignore/neglect them when deadlines dictate. Some of them will stick with you and some may fall away, but you just can't attend every single baby shower, birthday party, bridal lunch, church activity, or sports event that you did before you got started.
Boundaries are important and if you live with others they need to know that just because you're home, doesn't mean you're "off."
This whole deal has been a GREAT adventure! I've learned so many things that didn't have anything to do with nursing or medicine - and I hope the same for you, too.
I have social anxiety and am naturally quite introverted - nothing recharges me like having a full day where I don't have to talk to anyone. I am an Adult NP x 4 years now and very good at my job. Whether in clinic or at the hospital, when I see patients I am in control of the situation. I steer the conversation and I basically determine how long the encounter will last. I have found that when I am in my element, I have little to no anxiety. And I am a great listener, although doing so for hours on end drains me and then I come home to peace and quiet. I have a great husband who understands that I want to be in the same room with him in the evenings, but I may not want to talk much all night.
Now a work-related social event (cocktail party, holiday dinner, etc.) or a meeting will definitely make me anxious and I do all I can to avoid these situations. Hate small talk! When they cannot be avoided, I rely on pharmaceuticals to keep it together.
The short answer is, it depends. Each site and preceptor is going to be different. Some preceptors are great and will allow you to advance in autonomy, while always being close enough for help when needed. Some preceptors are control freaks who will never allow you to see a patient on your own, no matter how simple the reason for the visit.
At a good site you can expect:
Review of the schedule prior to beginning patient care. Who is on the "guest list" so to speak, what problems are they coming in for today, which ones are likely to be student-appropriate (depending on your level of experience at a given point), and a tentative idea of which pts you will see during the day with support from the preceptor. Having said all that, in primary care the schedule is only a starting point and very quickly can go straight to H@ll as soon as they phones start ringing at 0800.
Once you have an idea of which pts you may see, you can poke around in their charts, see what meds they are taking, problems list, etc. At the beginning you may go in with your preceptor and see the patient together; he or she should observe your interactions with patients, exam skills, comfort level, etc. prior to sending you into rooms by yourself.
Once you're ready for more independence, you may go in and introduce yourself to the pt and ask if they will allow you to see them and then your preceptor will see them and approve your care as well. You will come out of the room after history & exam and speak with your preceptor. At this point you will give report on the patient, your exam findings, and (in my case) 3 differentials. Then describe what tests or further exam techniques or history questions may be needed to eliminate 2 of the differentials and hone in on the most likely diagnosis. Then describe what treatment you would recommend (meds, physical therapy, OTC comfort care, call 911, etc.) and wait for your preceptor to make suggestions, share observations, give further direction, etc.
Granted, it does not always work that way. But it would be nice if it did!
I can see all y'alls points about nursing theory and whether or not it is necessary in today's nursing education. The powers that be certainly are hanging onto it as required curriculum for accredited programs!
In some regards I feel that theory could be offered as a sort of elective course...Theories of Thought in Professional Nursing, that would also include nursing history and the major players there. Of course it would be updated periodically since theory development is alive and well in nursing today.
I would almost rather make way for a course introducing us to alternate medicine/healing techniques since this is something that our patients consider part of "holistic" care and also speaks to cultural competency.
For me the value was in knowing how to find legitimate, high-quality research in any area where I need more information to provide up-to-date, evidence-based practice to my patients. Frankly, I could have lived without theory, but the research side of it is very important to me and I did not get that education anywhere else.
If you want to practice in the most beneficial way for your patients, you must know what constitutes good, solid, research that is applicable to your patient population. You must have the tools to dig and search for information on topics ranging from cultural issues (Why is my Native American patient non-compliant with the medications I've prescribed?) to pharmacotherapeutics (What is the best first-line medication for my African American male patient with HTN?) or your patients cannot benefit from all the research that is being done.
Incidentally, there is some really bad, invalid "science" going on and you have to know how to identify that, too. Otherwise you might be swayed into changing your practice by some "scientific study" done by a pharmaceutical company that really had a very low level of evidence.
P.S. I had 2 semesters of T/R as an undergrad and another 3 semesters during my NP program!
What you're feeling is entirely normal and expected. NP programs should be tough. Working full-time while taking a challenging course such as Pathophysiology might not be the best choice for you; I couldn't have worked full-time during my NP program. I know a few of my colleagues DID work throughout the program but the only ones I personally knew who succeeded had employers who were very supportive and committed to being flexible with working hours and scheduling.
At some point in the very near future, every NP instructor will hold either a DNP or PhD. Please do not be intimidated by your instructor's degree. He or she either knows the information and is able to relate it to students or not. The degree itself is not so important.
Take an informal poll of your cohort at school - how many of them are working full time during school? Perhaps you could share this information with your family and help them see that working full time may not be compatible with success in your NP program. You could really use their emotional support at this time. If they are not able to emotionally support you, find an alternate support system (extended family, friends, other students, church family, etc.) for yourself and make your own determination of your goals and priorities.
If you stop short of your goal just because it's harder than you thought it would be, because you have to work out alternate financial arrangements now that you realize working full time is not compatible with the time you need to study, because your family does not understand your struggles, or because being a NP involves hard work and exposes you to legal liabilities...I think you're going to miss out on something great.
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