Struggling NP student

zenman · May 17, 2011

Do not give up now! You can make it a little longer. It will be worth it trust me. Since you might not have time for therapy, we have meds to help you over this hump.

lvICU · May 17, 2011

Thanks, I won't give up! The end is in sight but I just wonder if I will ever start feeling better about my new position. I have never experienced anything like this before. I mean, I get good grades and I am learning a lot but when I get into the clinical setting, I panic and "choke" and my mind goes blank. This is from the girl who always remained cool, calm and collected during intense emergencies as an ICU nurse. I am just having a hard time synthesizing all this information when it counts. I wonder how long it will take for it to start to click?!?

Oh well, maybe meds will help :)

carachel2 · May 17, 2011

So are you doing FNP or AcuteNP? I think feelings of panic can be normal at some point in school, but it sounds like this is daily and starting to interfere? How have you done in the outpatient setting ?

And I'm sure you may have done this, but you need to make sure patho causes are ruled out. Early in NP school I was struggling managing just two classes. I had taken two classes the semester and did just fine, but here I was unable to focus, concentrate and I thought I was losing my everloving mind! Turns out my TSH was like 15! Ummm....NO WONDER!

t2krookie · May 17, 2011

Sounds like you have some confidence issues there. I might sugest talking to friends who have been in your shoes and are now working the job instead of styressing over perfection. Preferably over a glass of wine or a good single malt :)

Learn to laugh at yourself. It is almost over. Another point is, your clinical practice area may be a big part of the problem as well. Think about it, and identify the true source of the anxiety. It usually can b found.

mammac5 · May 18, 2011

I'm in my final semester, too, and it's been rough. I don't feel like I have enough confidence in the clinical area, I know a lot but tend to have trouble thinking clearly when doctors on my clinical rotation ask me questions, and I am pretty frightened about working as a new NP in the Fall.

Luckily one of our instructors informed us that it's normal to feel like an imposter at this stage of the game, so I'm having faith that it's going to get better. But some anxiety meds might not hurt to get through the short-term!

gettingbsn2msn, MSN, RN · May 18, 2011

Mamma,

I am also having the same issues. Its funny that I read this post as I went to the doc today to get my tsh level checked. They started me on strattera. I just took the first dose tonight. I will post how it works in a few weeks. They told me it takes this long to work. I think once we get into a groove we will be fine. I mean I have been calling the docs for years with abnormal labs, changes in patient status and ect.

lvICU · May 20, 2011

I'm in my final semester, too, and it's been rough. I don't feel like I have enough confidence in the clinical area, I know a lot but tend to have trouble thinking clearly when doctors on my clinical rotation ask me questions, and I am pretty frightened about working as a new NP in the Fall.
Luckily one of our instructors informed us that it's normal to feel like an imposter at this stage of the game, so I'm having faith that it's going to get better. But some anxiety meds might not hurt to get through the short-term!

Thanks for the encouragement! The "thinking clearly" problem is also where I get stuck. I can usually work through things in my head or on paper but when put on the spot in rounds I freeze up pretty bad. Then, I feel like an idiot and that doesn't help matters...I am just trying to keep a positive attitude and keep on trucking :)

Carachel: I have not done outpatient because I chose to do a critical care specialty with the ACNP program. In hindsight, I may not have chosen this route as I don't think that it suits me well. Part of the problem is that we do not have a set preceptor and we rotate units every few weeks. I have anxiety about meeting new NPs, attendings, residents, blah, blah, blah. It is a combination of many factors. I don't think it is my thyroid because I had it checked a few years ago, but thanks for the suggestion.

Advanced Practice Columnist / Guide · May 20, 2011

Thanks for the encouragement! The "thinking clearly" problem is also where I get stuck. I can usually work through things in my head or on paper but when put on the spot in rounds I freeze up pretty bad. Then, I feel like an idiot and that doesn't help matters...I am just trying to keep a positive attitude and keep on trucking :).

I don't know if we're thinking of the same thing but I'm kinda getting what you mean about "freezing up" on rounds based on my experience as a hospital-based NP and seeing NP students go through our service month per month. Is it feeling intimidated about presenting your patient's case to an audience of attendings, NP's, and residents? Or being afraid you'll get put on a spot with a question you couldn't answer? As nurses, we have a different style of presenting our patients during shift report to each other and we seem to get stuck on that mode, even after we we reach a point when we are already transitioning into a provider role. Don't feel bad, we all have to break these "old habits" and eventually we end up being good at talking the "physician" lingo (for lack of a better word).

I would approach rounds as a learning opportunity and accept the fact that you will expose your vulnerability because you don't know everything. Especially while still a student, it is the responsibility of those around you (attending or NP) to teach you anything you don't know about yet. This is your opportunity to attain knoweldge and those responsible for teaching you will not realize what your learning needs are unless you admit your deficiencies. However, a good rule to follow is to never show up to rounds unprepared. If you have to come in earlier to pre-round on your assigned patients and talk to nurses about the events of the previous night, and collect and write down pertinent data, then you should definitely do that.

A second rule to follow is to come up with some sort of organized script to use consistently on rounds with every patient you'll encounter. What we usually make our students do is to start by discussing overnight events first. Then start presenting your physical exam using a body system approach. Start with you neuro exam, then CV, then pulm, you know the deal. When you present by body system, you also incorporate other pertinent findings like labs and other test results that pertain to the body system you are discussing. For example when you discuss FEN/Renal exam findings, you not only say the I and O's, drain outputs, etc., you also state the results of the most recent lytes panel. For your pulm exam, you should also discuss the CXR findings. If you go by this approach, I guarantee that you will not miss a thing.

The last and most important part of your presentation is the assessment and plan. A good rule to follow is to start by summarizing your patient presentation in 1 or 2 sentences. An example would be "75 y/o M who presents with altered mental status, hypotension and tachycardia after 2 days of productive cough and 1 day of fever suggestive of sepsis felt to be from a pulmonary source of infection". Then, you'll again have to go by system when you state your plans. For example, you may start by saying. "I'm holding off on starting all sedating agents so we can accurately assess his neuro status" for you neuro plan. You can say "I will continue to trend his hemodynamic parameters and assess need for volume resuscitation based on MAP, CVP, etc." or "I will need to establish a more accurate assessment of volume status with a bedside echocardiogram which I'd like to order" for you cardiac plan.

By doing the above, you are presenting a patient in an organized manner that allows the others to learn about the case and assess how you problem-solve the patient issues at hand. You are going to get grilled on rounds. Medical students and residents get it all the time and NP students shouldn't be an exception. Take it as a learning opportunity but always come prepared.

lvICU · May 21, 2011

Jaun, thanks for the great advice and recommendations on presenting in rounds. I have a pretty good "script" that I use but your advice should help me streamline it even more. After reading your post, I am starting to get a more organized approach in my head. I appreciate your help.

dissent · May 21, 2011

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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.

Advanced Practice Columnist / Guide · May 21, 2011

dissent said:
[
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 and I am basing may advice on the setting I work in.