FNPs, I need your input!

BritFNP · Mar 10, 2014

Daily life:

Walk into primary care clinic with my coffee, sit at my computer and bring up the schedule. Its just me (FNP) and one MD (owner). My max day is 18 or less patients. Maybe three annual physicals and the rest acutes/med check or refills. I have time to talk to each patient, assess them and their needs, Rx for them, and order labs or diagnostic tests. Today so far I have had two physicals, one requiring a complete physical/PAP & breast exam, pharyngitis r/o gonnococcal infection, sinusitis, IT band hip pain, ADD med check, knee pain, abdominal pain, and a few others. I had one man this AM who was concerned about ALS as his father passed of it so I referred him to neurology for nerve conduction tests and other relevant studies. My patients are all insured, medicare, or cash pay. Our lab result turn over is usually 24 hours so I have labs waiting for me to be reviewed/interpreted (my favorite actually) in my free time or between patients. Often results require a redraw or depending on what they reveal - medications or referrals. I am in at 8 and out by 4:15. We are not a walk in office, so I always have my last patient scheduled around 3:50. Some reading this will probably say I have a pretty sweet gig. They would be right! 1/2 day on fridays. My doc is around, he has his own patients separate from mine. He is here if I need him. Even if not in office (vacation, golf, etc), he always makes himself available to me via telephone. I LOVE WHAT I DO.

futureeastcoastNP · Mar 10, 2014

Daily life:
Walk into primary care clinic with my coffee, sit at my computer and bring up the schedule. Its just me (FNP) and one MD (owner). My max day is 18 or less patients. Maybe three annual physicals and the rest acutes/med check or refills. I have time to talk to each patient, assess them and their needs, Rx for them, and order labs or diagnostic tests. Today so far I have had two physicals, one requiring a complete physical/PAP & breast exam, pharyngitis r/o gonnococcal infection, sinusitis, IT band hip pain, ADD med check, knee pain, abdominal pain, and a few others. I had one man this AM who was concerned about ALS as his father passed of it so I referred him to neurology for nerve conduction tests and other relevant studies. My patients are all insured, medicare, or cash pay. Our lab result turn over is usually 24 hours so I have labs waiting for me to be reviewed/interpreted (my favorite actually) in my free time or between patients. Often results require a redraw or depending on what they reveal - medications or referrals. I am in at 8 and out by 4:15. We are not a walk in office, so I always have my last patient scheduled around 3:50. Some reading this will probably say I have a pretty sweet gig. They would be right! 1/2 day on fridays. My doc is around, he has his own patients separate from mine. He is here if I need him. Even if not in office (vacation, golf, etc), he always makes himself available to me via telephone. I LOVE WHAT I DO.

Brit, thanks for that insight! How long have you been an NP? How long were you an RN before NP school?

Also, I'm curious how often you have to look things up? Are you going straight through your day without any sort of reference book/websites, or do you check it before you walk into the room? Do you prescribe off the top of your head or do you have to look up correct medications and dosing based on what you diagnose?

Just curious about how that works, thanks!

allnurses Guide · Mar 11, 2014

Hi,

I've been a FNP for just about 5 years. My first job was in adult primary care at an urban community health center. 25-30 patients per 10 hour shift, 15 min for each appt, be it a headache or full physical with GYN. Lots of complex medical conditions, psychosocial issues, and very few resources. No lab on site, so always waiting days for lab results. Rarely took a lunch break, took work home every day because I never had time to complete my charting at work. Crappy administrators, huge patient panels, wonderfully supportive peers, and experience that I never could have gained elsewhere. I did burn out after 3 years and have since moved into a private specialty practice (asthma, allergy, and immunology). I now see anywhere from 10-20 patients per day for a narrow range of medical conditions. I have lots of time to spend with each patient and can do a lot of education. I work four days a week and have every Friday off. I have time to eat lunch and go for a walk during lunch. I deal with occasional emergencies, but most of the time things are pretty routine. I've had the opportunity to really focus on a small range of medical conditions, and not have to be all things to everyone like I was in primary care. I see both kids and adults now, which I love. I get to have a relatively stress free, normal life with this job, unlike my first job. It is definitely a sweet gig! I also work per diem in an Urgent Care center, just to keep my skills current (and make extra $$). Today I saw 3 people with acute sinusitis, 2 asthma exacerbations, did some chemical allergy testing on a patient, did 3 annual immunotherapy evaluations,2 routine follow up visits, and counseled a family with a history of alpha 1 anti trypsin deficiency. I took a few patient phone calls, reviewed some labs, and helped out the nurse with some allergy shots when she got backed up. That's a fairly quiet day. Things will get much busier once pollen season starts.

As far as looking up things goes, I look up stuff every day, and probably always will. There's always something you don't know, and more to learn. Patients don't always present the way textbooks say they will, so you have to use your head and know when you need more information. You get to know the dosages for common meds that you prescribe routinely, but it's impossible to know dosing for every med out there. I use epocrates and up to date as my main resources.

futureeastcoastNP · Mar 11, 2014

Hi,
I've been a FNP for just about 5 years. My first job was in adult primary care at an urban community health center. 25-30 patients per 10 hour shift, 15 min for each appt, be it a headache or full physical with GYN. Lots of complex medical conditions, psychosocial issues, and very few resources. No lab on site, so always waiting days for lab results. Rarely took a lunch break, took work home every day because I never had time to complete my charting at work. Crappy administrators, huge patient panels, wonderfully supportive peers, and experience that I never could have gained elsewhere. I did burn out after 3 years and have since moved into a private specialty practice (asthma, allergy, and immunology). I now see anywhere from 10-20 patients per day for a narrow range of medical conditions. I have lots of time to spend with each patient and can do a lot of education. I work four days a week and have every Friday off. I have time to eat lunch and go for a walk during lunch. I deal with occasional emergencies, but most of the time things are pretty routine. I've had the opportunity to really focus on a small range of medical conditions, and not have to be all things to everyone like I was in primary care. I see both kids and adults now, which I love. I get to have a relatively stress free, normal life with this job, unlike my first job. It is definitely a sweet gig! I also work per diem in an Urgent Care center, just to keep my skills current (and make extra $$). Today I saw 3 people with acute sinusitis, 2 asthma exacerbations, did some chemical allergy testing on a patient, did 3 annual immunotherapy evaluations,2 routine follow up visits, and counseled a family with a history of alpha 1 anti trypsin deficiency. I took a few patient phone calls, reviewed some labs, and helped out the nurse with some allergy shots when she got backed up. That's a fairly quiet day. Things will get much busier once pollen season starts.
As far as looking up things goes, I look up stuff every day, and probably always will. There's always something you don't know, and more to learn. Patients don't always present the way textbooks say they will, so you have to use your head and know when you need more information. You get to know the dosages for common meds that you prescribe routinely, but it's impossible to know dosing for every med out there. I use epocrates and up to date as my main resources.

Thanks for this! As for the looking things up, I know this will sound silly, but when do you do it? Do you do your exam then run out of the room and look stuff up? Or do you read the chart, look up reported symptoms, and have an idea what to look for before you go in?

chillnurse, BSN, RN, NP · Mar 11, 2014

I have a quick explanation of what I do.

I work in a hospital

nightshift

admit 10-14 patients per night, sometimes less, usually not more

they come from the ER or xfers from smaller hospitals around.

i take call for about 50-90 patients per night, and get 10-60 pages per night from nursing staff on all floors minus sike.

patients may be simple chest pain rule outs

or train wreck transfers in septic shock on the ventilator.

I have full subspecialty and surgical back up so i can call the critical care/PULM, or anybody else I need.

ER doctor runs the codes, i read the chart off to them.

even though i have backup, i still have to order pressor drips, heparin drips, etc very often and manage these

i also have my attending on call at all times by phone if i need anything.

an admission process goes as such:

pull up old H P if able, see patient for an h and p, order labs n rads, write other orders, dictate history and physical.

rinse repeat.

discharge summaries or socialize with staff when not busy.

transfer patients to the nearest teaching hospital u of kentucky, if needed for neursurgical or trauma.

allnurses Guide · Mar 11, 2014

Thanks for this! As for the looking things up, I know this will sound silly, but when do you do it? Do you do your exam then run out of the room and look stuff up? Or do you read the chart, look up reported symptoms, and have an idea what to look for before you go in?

I review the patient's chart before I see them, and will look up anything I have a question on at that time. If I have to look up a dose or interactions, I'll do that on my phone in the exam room. Most of the standard doses are already in the EMR prescribing module. On occasion I will leave the room to do more extensive research or to ask a colleague a question. I will sometimes have a colleague come in and see the patient with me if I'm not sure what's going on, like an unusual rash. Everyone does it, and should do it if you're not sure. I like to know the patient's history, but I try not to go in with a pre-conceived notion of what is wrong. I go through the whole differential diagnosis process to make sure I'm doing right by my patients.

BritFNP · Mar 12, 2014

Hi!

I have been a NP for 6 months! RN for 2 years prior to NP school. I always look things up! There are so many different disease processes and medication options, you have to use your resources. I often know what they patient is coming in for generally…although CC: Abdominal pain (for example) doesn't offer you much direction until you've spoke with the patient. There are a lot of medications I can Rx off the top of my head, but there are a lot that I can't. It takes time. In general, patient's haven't minded my saying,"You know what? I want to double check something right quick on this med." With that said, my family practice MD asks me questions too and asks me to look up stuff for him often. Guidelines change, we have to stay relevant :)

OCRN3 · Mar 12, 2014

RN 9 years before ACNP, then FNP. Working in clinic was pretty fun. Started off with dime coffee. I'd come in 930, office opens at 9. I would come in late because it was a walk in clinic and the MAs had to register the clients. At about 945 i would start seeing clients in the room. Most of my clients were episodic issues, colds, routine follow up. I do lots of adjustments to medications and some referrals. Great thing is my office had a lab and X-ray so anything semi urgent I could do some labs. So M-TH 945-6, then on call for every other weekend for the MD. That's pretty much it.

Take lunch 1 pm, then continue seeing patients till 5. 5-6 paperwork.

Sent from my iPhone using allnurses.com

Trauma Columnist · Mar 12, 2014

I'm a CNS in an APN role. I work in a very large (17 physician) nephrology practice.

I manage 210 chronic hemodialysis patients in four geographically separate clinics. I travel approx 25-110 miles per day, averaging about 70 miles/day. I see anywhere from 30-70 pts/day. These are chronic pts that I have taken care of for many years.

I take calls from my four units plus call for any other APN or PA that is not working (we rotate this call). We currently have five APNs/PAs in our practice. I also am responsible for labs/xrays/tests/referrals, interaction with other providers. I field calls frequently from other providers about renal dosing of meds or adjustments to be expected in test results.

I work an average of 50-55 hours per week and am very flexible with my hours. I am on call during the week from 0700-1700 and every fifth weekend I take phone call for 20 plus dialysis units (about 500 pts) from 0700-1900).

I look up info all the time - I use UpToDate most of the time.

I've been an APN for 8 years and was an RN for 14 years prior to this.

futureeastcoastNP · Mar 12, 2014

I'm a CNS in an APN role. I work in a very large (17 physician) nephrology practice.
I manage 210 chronic hemodialysis patients in four geographically separate clinics. I travel approx 25-110 miles per day, averaging about 70 miles/day. I see anywhere from 30-70 pts/day. These are chronic pts that I have taken care of for many years.
I take calls from my four units plus call for any other APN or PA that is not working (we rotate this call). We currently have five APNs/PAs in our practice. I also am responsible for labs/xrays/tests/referrals, interaction with other providers. I field calls frequently from other providers about renal dosing of meds or adjustments to be expected in test results.
I work an average of 50-55 hours per week and am very flexible with my hours. I am on call during the week from 0700-1700 and every fifth weekend I take phone call for 20 plus dialysis units (about 500 pts) from 0700-1900).
I look up info all the time - I use UpToDate most of the time.
I've been an APN for 8 years and was an RN for 14 years prior to this.

Impressive. Your poor car! lol

chillnurse, BSN, RN, NP · Mar 12, 2014

Wow trauma that is quite a load there. I commend you for being able to do all of that. Sounds like a very interesting position to say the least. Kidneys seem to be a complex subject. At least to me and my small brainwidth. Great to hear about all the opportunities out there