started clinicals, need advice

[Qka]

Hi friends,

I am in my first clinical semester. I feel like I finally learn what I have to learn. However, I feel ovewhelmed. I feel like I studied a lot, know a lot, but I am still not comfortable. I would appreciate any advice you have to make this process easier. Maybe some guidlines, protocols, something like that? How to keep track of new changes, new meds? Maybe some journals are helpful?

Another thing: what is the best way to organize your notes? Right now I started a notebook where I put my lecture notes in. But I feel it is not the best way to do it. Any advice is appreciated.

[BostonFNP, APRN]

My question is about the best intervention as Np for this type of problem,this is part of certification exam .

I assumed that's what you were getting at

[BostonFNP, APRN]

Metformin or Glypizide and lifestyle changes should lower a A1C levels at least a few % before jumping into insulin.

ACE inhibs are good first line meds for DM as well as ARBs. What has his BP trend been?

Basic Zocor or Lipitor for hyperlipidemia, watch for muscle pain....

You should invest in Uptodate.....

NPs and NP students should be aware of and understand the major chronic illness guidelines because the above is an example of the incorrect way to practice. It is not this simple.

I often have students who try and make treatment decisions based on meds they have seen as a nurse rather than understanding the proper way to treat.

UpToDate is a great investment for practice.

[Adenium]

I also like Prescriber's Letter - they have nice concise newsletters and a big archive of articles on different topics including many algorithms. Wish I'd subscribed before starting clinicals. I also feel like going thru board review helped distill a lot of things in a way that my classes didn't. We had a lot of long wandering lectures that often confused things more. Get some good review books or used Fitzgerald CDs/workbooks etc. That helps when you need a quick reference and starting point.

[Dranger]

NPs and NP students should be aware of and understand the major chronic illness guidelines because the above is an example of the incorrect way to practice. It is not this simple.

I often have students who try and make treatment decisions based on meds they have seen as a nurse rather than understanding the proper way to treat.

UpToDate is a great investment for practice.

Exactly how is this wrong info?

Lifestyle changes=>oral agents=> insulin use (long acting first then work to sliding scale).

A1C levels should not be dropped abruptly but lifestyle and oral agents have proven to lower A1C levels by a couple % percentages over time safely.

Ace inhibs are first line treatment for uncomplicated DM patients per JNC7 and ACC....

All of this info doesn't come from my experience but rather hard and fast guidelines you mentioned from pocket medicine, diabetic/cardiology associations and Uptodate.

[anh06005, MSN, APRN, NP]

I am currently in the middle of a clinical semester and am set to graduate in December. I keep my "book work" in a separate notebook from my clinical stuff. I have a clinical cheat sheet type thing made up in my clinical notebook wih stuff I struggle wih (peds doses of abx along with concentrations of liquids, anemias, hgba1c's to avg blood sugar, etc). I have asked every single preceptor so far and they all say the same thing - with experience you figure out which drugs work better for your population and for each situation. Each of my preceptors so far have been great and generally follow the same general guidelines BUT each may prefer one drug over another in the same class.

This upcoming week I start in a rural clinic that is slower (about 15 patients per day) and am looking forward to getting to discuss and think out each situation.

I keep trying to reassure myself that I was terrified when I graduated with my RN and started seeing patients and I'm sure I will be with my FNP too.

To me what matters is that I know what I'm weak in, I'm working to make it better and I know reliable sources where I can get information I don't know.

But yes I wish there was an algorithm for everything too!

[BostonFNP, APRN]

Exactly how is this wrong info?

It is not guideline based and over simplified.

Lifestyle changes=>oral agents=> insulin use (long acting first then work to sliding scale).

A1C levels should not be dropped abruptly but lifestyle and oral agents have proven to lower A1C levels by a couple % percentages over time safely.

Initial therapy for diabetes is based on a number of factors, most important the presenting A1C and the renal status of the patient (not to mention allergy history, as this is obvious). The linear progress you suggested is no longer recommended.

Current guidelines call for both metformin (if not contraindicated by real status) and lifestyle management at the time of diagnosis provided the A1C is 10 then initial therapy is lifestyle modification + metformin + insulin; this can be in the form of basal insulin, intermediate insulin, or single-meal bolus (or a combination) depending on the severity of the A1C.

Sulfonureas are largely falling out of favor as secondary oral agents.

Ace inhibs are first line treatment for uncomplicated DM patients per JNC7 and ACC....

JNC8 and the European guidelines are now the standard for HTN management. ACEI/ARB are a good renal protective medication for those with DM; diabetes also have strricter target range for BP. Most HTN requires combination therapy. Appropriate anti-hypertensive agents vary by comorbidity, age, race, renal status, and of course systolic pressure.

All of this info doesn't come from my experience but rather hard and fast guidelines you mentioned from pocket medicine, diabetic/cardiology associations and Uptodate.

I would be curious for you to cite the guidelines for the information you posted. Please share.

[Dranger]

It is not guideline based and over simplified.

Initial therapy for diabetes is based on a number of factors, most important the presenting A1C and the renal status of the patient (not to mention allergy history, as this is obvious). The linear progress you suggested is no longer recommended.

Current guidelines call for both metformin (if not contraindicated by real status) and lifestyle management at the time of diagnosis provided the A1C is 10 then initial therapy is lifestyle modification + metformin + insulin; this can be in the form of basal insulin, intermediate insulin, or single-meal bolus (or a combination) depending on the severity of the A1C.

Sulfonureas are largely falling out of favor as secondary oral agents.

JNC8 and the European guidelines are now the standard for HTN management. ACEI/ARB are a good renal protective medication for those with DM; diabetes also have strricter target range for BP. Most HTN requires combination therapy. Appropriate anti-hypertensive agents vary by comorbidity, age, race, renal status, and of course systolic pressure.

I would be curious for you to cite the guidelines for the information you posted. Please share.

How is that not what I suggested? Combo of lifestyle and oral agents then go from there. Of course with metformin renal function is monitored.

There are several classes or oral agents I didn't mention those were just starters....I know the ceiling for A1C and treatment but the OP didn't list it.

Like I said ACE inhib first choice barring previous failure or ethnicity like AA and angiodema. BB combo for CHF...CCB for CAD....diuretic for retention. I said first line but the OP gave scant info.

Next time I'll include everything if you aren't willing to give me the benefit of a doubt.

[NaShaH]

What do you do with patient high TG start niacine and TLC what is the next action?

[NaShaH]

What medication had the most research for HTN ?

[VIDASH1]

What about MPR?