Struggling NP student - page 2

by lvICU 12,490 Views | 27 Comments

I am in my final semester of NP school and I am having a hard time. It is not the work load but the clinical experience that I am having major difficulties staying focused. I have 9 years of RN experience and I really thought... Read More


  1. 4
    [
    There are 3 types of presentations that are used in Medicine: Admissions, daily, or ICU
    Obviously admission notes and presentations should be very detailed as should ICU. Daily presentations should NOT. Only ICU notes should be by system.

    I am assuming ivICU is presenting for general floor patients who have been in the hospital. That presentation should be in the SOAP format. This is done using the following:

    ID- Name, age, why she/he came in

    Subjective: Overnight events. Pertinent complaints that AM. (I often include if they got a procedure or some imaging but this tends to go under objective technically but it lets the listener know to listen for the results)

    Objective:
    - Vitals (T, P, BP, R, Sat) and Ins/outs
    - PERTINENT physical exam, especially changes. Your preceptor may like to hear detailed physical, others really only want to hear any abnormalities or changes
    - Meds (mainly changes and pertinent)
    - Lab data
    - Imaging

    A/P
    CONCISE is the key it needs to include the important stuff but for very stable things it just wastes time.

    In general the way to look good is to know what is pertinent so that your presentations can be concise.


    For example
    Mrs Smith is a 57 yo with ischemic cardiomyopathy who presented with volume overload
    Overnight she had no acute events. She complains of shortness of breath this morning. She did get her echo yesterday.

    Her vitals: afebrile, pulse 60-75 BP 138-145/70-88 R 24 Sat 98% on Room air.
    I/o 1200/3200 for a Net negative of 2L
    Physical exam shows
    An unchanged HEENT exam
    JVP 14cm, 2/6 holosystolic murmur at the apex and an S3. Her lungs had bibasilar crackles. Her abdomen was benign and she had 2+ pitting edema to her thighs. Her extremities were warm

    Meds: Her lasix was increased to 80IV BID. Other meds the same

    Labs show stable Na, K and Cr. Her crit dropped slighly from 36--> 30. INR is 1.8 today, increased from 1.5 yesterday

    She had her echo which showed an akinetic lateral wall with a dilated LV. Her EF was 20-25%, RVSP of 60. Her valves show some mild mitral regurgitation.

    A/p Mrs Smith is a 57yo with ischemic cardiomyopathy with an EF of 20% who presented with volume overload. Despite diuresis she remains fluid overloaded based on JVP and edema. Her dilated LV has likely caused her mitral regurgitation and is likely exacerbating her heart failure.

    1) Ischemic CM
    - continue aspirin
    - Continue diuresis
    - Cr stable despite diuresis

    ETC.

    PS I am an IM doc at Hopkins.
    ghillbert, missvictoriat, SkiBumNP, and 1 other like this.
  2. 0
    Quote from dissent
    [
    There are 3 types of presentations that are used in Medicine: Admissions, daily, or ICU
    Obviously admission notes and presentations should be very detailed as should ICU. Daily presentations should NOT. Only ICU notes should be by system.

    I am assuming ivICU is presenting for general floor patients who have been in the hospital. That presentation should be in the SOAP format. This is done using the following:

    ID- Name, age, why she/he came in

    Subjective: Overnight events. Pertinent complaints that AM. (I often include if they got a procedure or some imaging but this tends to go under objective technically but it lets the listener know to listen for the results)

    Objective:
    - Vitals (T, P, BP, R, Sat) and Ins/outs
    - PERTINENT physical exam, especially changes. Your preceptor may like to hear detailed physical, others really only want to hear any abnormalities or changes
    - Meds (mainly changes and pertinent)
    - Lab data
    - Imaging

    A/P
    CONCISE is the key it needs to include the important stuff but for very stable things it just wastes time.

    In general the way to look good is to know what is pertinent so that your presentations can be concise.


    For example
    Mrs Smith is a 57 yo with ischemic cardiomyopathy who presented with volume overload
    Overnight she had no acute events. She complains of shortness of breath this morning. She did get her echo yesterday.

    Her vitals: afebrile, pulse 60-75 BP 138-145/70-88 R 24 Sat 98% on Room air.
    I/o 1200/3200 for a Net negative of 2L
    Physical exam shows
    An unchanged HEENT exam
    JVP 14cm, 2/6 holosystolic murmur at the apex and an S3. Her lungs had bibasilar crackles. Her abdomen was benign and she had 2+ pitting edema to her thighs. Her extremities were warm

    Meds: Her lasix was increased to 80IV BID. Other meds the same

    Labs show stable Na, K and Cr. Her crit dropped slighly from 36--> 30. INR is 1.8 today, increased from 1.5 yesterday

    She had her echo which showed an akinetic lateral wall with a dilated LV. Her EF was 20-25%, RVSP of 60. Her valves show some mild mitral regurgitation.

    A/p Mrs Smith is a 57yo with ischemic cardiomyopathy with an EF of 20% who presented with volume overload. Despite diuresis she remains fluid overloaded based on JVP and edema. Her dilated LV has likely caused her mitral regurgitation and is likely exacerbating her heart failure.

    1) Ischemic CM
    - continue aspirin
    - Continue diuresis
    - Cr stable despite diuresis

    ETC.

    PS I am an IM doc at Hopkins.
    You are correct. I am an ICU NP at UCSF and I am basing may advice on the setting I work in.
  3. 0
    Quote from dissent
    [
    There are 3 types of presentations that are used in Medicine: Admissions, daily, or ICU
    Obviously admission notes and presentations should be very detailed as should ICU. Daily presentations should NOT. Only ICU notes should be by system.

    I am assuming ivICU is presenting for general floor patients who have been in the hospital. That presentation should be in the SOAP format.
    Dissent, thanks for the info on the patient presentations. I am actually presenting on ICU patients only. I am doing pretty well on the actual presentation part. My plan is what needs the most help (I have never been told this, it is just my self-evaluation).

    I also struggle when I am asked a random question about a lab or disease process during rounds. The physicians don't always ask a question that is completely pertinent to my patient so it is sometimes hard to be prepared, although I try to be ready for anything. I have trouble thinking when put on the spot like that. I will continue to work through this though. Again, thanks for the info. I can use all the help I can get
  4. 0
    Quote from lvICU
    Dissent, thanks for the info on the patient presentations. I am actually presenting on ICU patients only. I am doing pretty well on the actual presentation part. My plan is what needs the most help (I have never been told this, it is just my self-evaluation).

    I also struggle when I am asked a random question about a lab or disease process during rounds. The physicians don't always ask a question that is completely pertinent to my patient so it is sometimes hard to be prepared, although I try to be ready for anything. I have trouble thinking when put on the spot like that. I will continue to work through this though. Again, thanks for the info. I can use all the help I can get
    Another thing that might help is to have a A/P for every system. One of our attendings teaches the residents to have a diagnostic and a therapeutic differential for each system. For example if you have a patient in shock you would list what the differential in and then what tests you would do to rule in or out the differential. Then for treatment you would list what the different treatment options for the differential are. This allows you to think about the different processes going on with the patient. Also some of the differential may already be done so you can include that but state the test is already done and what the results are.

    For example shock. MAPs 50's.

    Diagnostic differential - hypovolemic vs cardiogenic.
    DDx - Echo yesterday showed EF 65 percent with normal wall motion. Check if patient is volume responsive. CVP is 12. Vigeleo placed for SVV.

    Then SVV 20 with CO 7 CI 2.5 showing adequate cardiac function.

    Therapeutic intervention Bolus with NS to so SVV < 10 consider VBg etc.

    Even if you can say its not a particular process this method forces you to think why its not or what piece of information you have that rules it in or out. Then if someone asks you a question you can discuss the process intelligently.

    As far as notes, we are using a hybrid note. Our PE is system based but our A/P is problem based. This is strictly a billing issue. Our coders want the notes to have a problem based system. They were getting claims rejected because the problem billed on was not spelled out for the insurance companies. I still present the problems in a system based approach, I just write the A/P in a problem based format.

    I'm a PA in a tertiary SICU.
  5. 2
    Your level of anxiety is perfectly normal. I can remember standing in front of an Pulmonary/CC or Cardiology Attending, several per day/week, helping present and discuss ICU patients. There was a fellow, third year IM, intern, medical student, DPharm (usually with a student), RN (usually with a student) and LCSW, Case Mgr and Service NP or PA. This team can be a bit intimidating until you begin to realize, they are all there for a reason, the patient. Not to poke fun at you or ask silly questions, despite the looks on the faces you may get (rare). They understand where you are at and hopefully where you will be in a few years. Think of this as an opportunity, as most NP/PAs do not get this kind of experience.

    Take the advice of these good folks and whatever you do, don't forget:

    introduce new team members, guests
    review cultures/path results
    how long a tube has been placed, specifically those in a vein or artery
    asking for further questions, suggestions
    close the door to the room, family loves to listen (and often misunderstands)

    Get through this, work on improving your style and template. After a while, you'll know what's important (and what's not).
    ghillbert and lvICU like this.
  6. 5
    Quote from lvICU
    Dissent, thanks for the info on the patient presentations. I am actually presenting on ICU patients only. I am doing pretty well on the actual presentation part. My plan is what needs the most help (I have never been told this, it is just my self-evaluation).

    I also struggle when I am asked a random question about a lab or disease process during rounds. The physicians don't always ask a question that is completely pertinent to my patient so it is sometimes hard to be prepared, although I try to be ready for anything. I have trouble thinking when put on the spot like that. I will continue to work through this though. Again, thanks for the info. I can use all the help I can get
    Well then scrap basically everything I said about presentations. In the ICU as Juan said, it is 100% by system- Basically SOAP format per system.

    The "pimping" is really just to help teach you. I know it can be very anxiety provoking but once you realize you are not supposed to know everything, you will start to relax and everything will go smoothly. On rounds they are specifically trying to push you to the limits of your knowledge so that you can learn. If they just tossed you softballs all day long you'd learn nothing. They want you to take a step back and a give yourself a second to think before speaking and showing your thought process. They'll know you are bright and if your thought process is wrong, they will guide you through the rest. Just realizing they are not out to get you is more than half of the battle.

    Good luck
    ivyleaf, ghillbert, GM2RN, and 2 others like this.
  7. 1
    Quote from dissent
    give yourself a second to think before speaking and showing your thought process.
    That's a good piece of advice right there.
    CCRNDiva likes this.
  8. 2
    Quote from dissent
    Well then scrap basically everything I said about presentations. In the ICU as Juan said, it is 100% by system- Basically SOAP format per system.

    The "pimping" is really just to help teach you. I know it can be very anxiety provoking but once you realize you are not supposed to know everything, you will start to relax and everything will go smoothly. On rounds they are specifically trying to push you to the limits of your knowledge so that you can learn. If they just tossed you softballs all day long you'd learn nothing. They want you to take a step back and a give yourself a second to think before speaking and showing your thought process. They'll know you are bright and if your thought process is wrong, they will guide you through the rest. Just realizing they are not out to get you is more than half of the battle.

    Good luck
    I didn't think about that. That is great advice. It never occurred to me that they are pushing the limits to facilitate learning instead of just testing her current knowledge. This tidbit is going in the vault!!
    ghillbert and mammac5 like this.
  9. 1
    The anxiety you feel is normal. You are adjusting to a new model of care and it is hard, especially when you are used to being the "expert" in your field and comfortable in your RN role. The points given in the previous posts are very good. The "pimping" really is for your benefit to help you learn to think critically and on your feet (very important in the APN role you are pursing). Remember though, it is ok to say you do not know if you don't, especially if you give yourself a second to really think about the question. I had plenty of times in grad school where I got asked a question in clinical and, after taking a second to think, I would be honest and tell them I did not know! You have to be prepared to do your follow up research/reviewing texts etc to make sure you DO learn the answer. They do not expect you to know everything. You are a student. Relax, have confidence in yourself and your abilities and you will be fine. Good Luck!
    CCRNDiva likes this.
  10. 0
    I am in my next to last semester of NP and I feel the same as you I've never liked clinicals, hated them, actually, but NP school is especially bad because of the number of hours you have to spend on them. I have also found myself trying to find reasons not to go, last semester was terrible. I did clinicals three days a week and worked every weekend and it was really messing with my mind. If we can hang on I think we will be glad we did, though I don't know that I really care for the primary care specialty, which is what my program is. Same old thing, accommodating drug seekers, watching some sweet little old person deteriorate more with each visit. Don't know that it's for me, but I've gone too far to jump ship now.


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