gatherswool 1,356 Views
Joined: Mar 12, '06;
Posts: 25 (36% Liked)
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Aaaaaaand here we see the fundamental difference between family and pedi people. Family people know that most babies are totally fine and do best with a little too little intervention rather than too much. Pedi people have actually cared for that one baby out of a few hundred thousand who had a bili of 13 at 36 hours, but oh, hey, also has g6pd and did I mention mom is O- and missed the rhogam appointment? So yeah, crap, that bili is the one the lab left sitting in the window for an hour and when it's redrawn in the ED at 72 hours it's 35.
That obviously wasn't the case here. But I think most pedi people would say that if newborns don't terrify you, you shouldn't be treating them. Most family folks will tell you terrorizing parents is bad for bonding and for the like 90% of babies who are fine. Personally I try to act like Family and think like Pedi, but I will admit that I exclusively take my own kids to Pedi people.
You've doubtless already heard this, but the perennial cause of ANYTHING in the first two weeks is sepsis, so even though a mild hyperbilirubinemia is demonstrably good for babies, I'd recommend a quick once-over for mom's GBS status and rupture time, then document reviewing s/sx infection with the responsible guardian. And bili tool of course, remembering to assess the appropriate risk level based on gestational age. Personally I treat all ABO setups as "HDN" since the Coombs is a crap test on neonatal hemoglobin. And make sure baby actually had a newborn screen done - you'd be amazed how many fall through the cracks.
Good luck with the newborns - and us Pedi people! Remember, we're the way we are because kids (and especially babies) almost never go bad - but when they do, damn they go bad quick, and hard, and ugly. And you'd best believe that someone's going to come looking for a scapegoat, reasonably or not.
Actually, those are NAPNAP's stats for 2009-2010, so pretty recent. Bear in mind that the median salary for a pediatrician is just $148,000. Pediatric pay is notoriously less than other areas -- hence higher pay for seeing adults in the VA.
I live in the northeast, where nursing salaries are notoriously high but NP salaries are pretty milquetoast. I know very few NPs making over 100K, and they're all adult acute or family -- the PNPs here seem to gross more along the lines of $80-90k.
BUT -- there's good(ish) news. Many, if not most, PNPs work part time. That also impacts salaries, since they're usually calculated on a per-year basis and not hourly. There's a big difference between making $90K working 40 hours a week (=$43/hour) and making $90K working 30 hours a week (=$57/hour).
Sad but true: peds just doesn't pay. Hopefully a little thing like $20-40K a year won't stop you from pursuing the best job in the whole world, though!
Am I bad nurse for thinking that if you've gotta be (genuinely) sick, orientation is the time to do it? Could you just find someone willing to take you on as a temporary preceptor and work an extra shift this week? That way you don't extend your orientation time beyond your current schedule.
Since orientees have to learn, and not just scut, in a way they're even less useful than techs (I say this as someone who just came off orientation at a new hospital myself). Work-wise you'll never be less missed by the other floor nurses and charge than during orientation -- though I'm sure that emotionally it feels much worse. Of course, they still can't tell if you're a hard worker who made a reasonable choice for important self-care or a malingerer who doesn't even respect the sanctity of orientation. Showing up with a doctor's note and ready to work a make-up shift will probably go a long way, though. So will giving the strongest first impression you can on subsequent shifts. Good luck, and hope you feel better soon!
That sounds awful! Yes, probably most women are technically able to breastfeed -- but very large percentages (depending on your populations) will need a LOT of help in order to do it. You can't get *80%* in most communities without lots and lots of help, especially with a high C-section rate. What is the hospital thinking??????
I tend agree with the leave-on-good-terms-once-you've-found-another-job idea. If you're not too exhausted to approach management one more time, you could always call around to Baby Friendly hospitals, find out what their ratios are like, and share that with your administrators. I once worked at a safety-net, Baby-Friendly hospital with union nurses (ie a poor hospital with well-paid staff) where the ratios were virtually never higher than 4:1 -- on nights! With great techs! And downsizing *always* took into account L&D's census.
So sad to hear the hospital is approaching things this way. You can probably abuse nurses to force certain things to happen -- ABX within a given time frame, documented turns q2H, etc -- despite ridiculous ratios, but breastfeeding, like labor, can't be forced by anyone. I won't even get into the risks they're taking with newborns by forcing early discharges (our poor hospital had a policy that any baby born after 8pm got either an extra day or VNA; mom's choice). Ask your administrators to check out the kernicterus case studies sometime and decide what it's worth to them never to risk a sentinel event...
The MGH plastics service uses leeches regularly for replants, but not debridement. They're generally used when something (a finger, ear, etc) is being replanted and the arterial supply can be reconnected but only minimal/no immediate vascular return can be ensured. Of course the little buggers constitute a biohazard as soon as they leap off the finger/ear and start wriggling across the floor to freedom, bellies full.....
I've heard rumors that MGH used to use maggots to debride; it seems collagenase and vac dressings are far more popular now. Nobody wants to wrangle invertebrates these days.
Here's some great info on what different states license NPs to do:
Each individual state determines who can prescribe, and who can prescribe what substances. Usually only MDs, DOs, DMDs, and DVMs have completely independent prescribing authority (each with its own specific limitations), though about 13 states and DC also grant this to APRNs. For example, NPs in Alabama cannot practice independently or prescribe anything other than OTCs, while NPs in Mississippi can practice and prescribe completely independently.
To the best of my knowledge, all states classify any nursing doctor (DNP, DNSc, PhD) the same way as any other APRN. Certainly IF/when the DNP becomes the minimum degree for practice, they'll all be seen as the same. (Along the same lines, becoming a doctor of clinical psychology lets you be called "doctor" -- in most states --, but it doesn't let you prescribe.)
CNM practice rules may be slightly different; it would probably pay to get in touch with a faculty member at one of your state's midwife schools to find out exactly what your state laws are.
My own PCP's health center uses this system, something I really appreciate after once struggling mightily to get back time-sensitive test results from a different health center.
The MyChart info is much more limited than what you would find in the actual EPIC chart, and at least in my PCP's case, it features lots of bells and whistles to allow you to talk with clinic staff and/or your PCP about what you see. It's pretty cool, but not overwhelming, even for my completely non-medical husband. If anything, MyChart may well placate those who insist on getting their whole chart to take home and surf the web with.
I often think that patients who want it should have easy access to their real chart (most EMRs automatically convert things like "SOB" to their full phrasing. Though I wonder what typing "LOL" will get you!). So many lay people think that something is being hidden from them by healthcare professionals, why not give them full transparency? It might also help those who need it to appreciate that a fuller education than 5 minutes on "Dr. Google" is necessary to make sense of all that data.
There's another way to do the penny problem...... and to cut the cake, you just need to think three dimensionally. I love these kinds of questions! Though I'd almost certainly have a seizure if asked to do the train one; I have severe Post Calculus Stress Disorder.
Re: "George" -- isn't the only way to succeed around surgeons to be both weirder and cleverer than they are? Luckily at least one of those isn't too hard.
The strangest interview I ever had was for an NP position in specialty Pediatric care. Hospital HR had me come in from a couple of states away to discuss this very specialized position, which I had very specialized experience for, and then proceeded to ask me questions about how I would deal with adult med/surg/cardiac patients as a floor nurse. No pediatric or advanced practice questions at all. It was truly surreal. I didn't get the job, possibly because I kept asking the interviewer if he was sure I was in the right interview!
The Youth Risk Behavior Survey is the gold standard for getting this kind of data on kids from grades 6-12. In fact, if you would rather save time and not do your own survey, you could use their data for your state to talk with the school.
You can find a copy of the survey, as well as their data, at http://www.cdc.gov/healthyyouth/yrbs/index.htm
I definitely recommend using the YRBSS protocol if you're going to do a survey; for one, you'll be helping a lot of people by collecting more data, and for another, you may protect yourself somewhat from risk of liability if anyone complains -- or decides after the fact that their child was somehow "harmed" by completing the survey. (It's not inconceivable, and this is why many IRBs make it nearly impossible to perform any untested sexual health surveys with adolescents).
I'm also always surprised to find how few school systems are using evidence-based programs to reduce STDs -- the programs are definitely out there, but I think that sometimes we adults imagine that we "know" how to prevent STDs just by being smarter than a bunch of limbically-driven, prefrontal-deprived, hormone-washed teenagers. School nurses and School-Based Health Center staff can be great resources for schools that are interested in using proven programs, at least when we can tactfully suggest to a school that the Promising Practices Network might be a bit more useful than the usual Syphilitic Slideshow...
Good luck! Reducing STD load among adolescents is a very pressing issue for public health -- not to mention the many individual kids whose health and future fertility are at risk!
Complaining (especially complaining about your assignment) is actually a communication mechanism employed by adult floor nurses. The combo of clicks, whistles and groans that sounds like "I can't believe [charge] gave me 2 boarder patients AND [John], [Jane], and [Joey] while everyone else is on the web shopping today!" actually means something completely different in their language, like "gee, it's nice out today," and "where's the coffee pot?"
I love being in peds and working in the sort of place where people are ok with SHOWING that they're happy to work here. Pediatric work is a lot more detailed than adult (really? I have to count that 50ccs in my I&Os? And do neuro checks more than once a shift?), which takes a little adjusting for us former big people nurses, but it's the details that reward us with the extra time we spend with little Johnny, counting every drop of saline flush.
OK, gotta run, I have this ridiculous assignment today that you would not believe....
Beautifully written. I hope you do more of these! This is one of the reasons why I love nursing -- it's amazing how much patients give us.
All of the steak-eating oil-changing guys are married.
I guess I'm going to buy some more cats. *sniff* Can felines become legal power of attorney for healthcare decisions?
Crunch numbers carefully unless you're SURE you'd rather be an NP than an RN. Hospital-based RNs in Boston can make a LOT more than NPs, and an accelerated BSN not only costs less, it gets you back out there and making money sooner. After 3-5 years as an RN you can make as much as a new NP *without* significant OT or differentials (extra money paid for working weekends, nights, holidays, etc). Nurses who already have experience on the floor generally find that becoming an NP represents a pay CUT. Of course, if you love the NP role, it's worth it, and as long as you can find full-time work you certainly won't starve -- assuming you don't have undergraduate loans, of course.
The only specialty that will instantly make you wealthy is gas. (I'm pretty sure that when you graduate CRNA school they hand you a Lexus and a yacht, but these days maybe it's only the yacht...) Hey! You can't blame a jealous PNP! We're lucky to find anything over 80k...
If there's an area you're especially passionate about, try emailing the nurse manager for that unit first, then, if all goes well, contacting HR. But do be aware that most hospitals in Boston require a BSN. If you're not 100% sold on the acute care track, you could probably find a job at a community health center. The pay and benefits are much better than in stand-alone primary care practices, and you get exposed to a lot of different (outpatient) stuff. It's not impossible to go from a community health center job to a hospital job after a few years, but of course it's a lot easier to go from one acute job to another.
Be sure to look through craigslist to figure out about how much you'd pay for rent -- I wouldn't count on anything less than $600/month for a share with at least 1 or 2 other people.
A few community health centers that see a lot of volume/are well known in Boston:
Dorchester House MSC
South Boston Community Health
East Boston Neighborhood Health
Many hospitals also have busy outpatient divisions and may provide an entry point, *if* they hire ADNs -- you'd have to check their HR websites, I only know for sure that MGH and the BID don't.
Good luck, and happy travels!
Hmm....I'm a PNP, so my NANDA knowledge isn't too fresh, but I do work in a well nursery. A term baby with a difficult delivery and subsequent TTN will usually have the following issues:
immediate inability to feed due to tachypnea
subsequent breastfeeding difficulties secondary to mom/baby separation
feeding difficulties due to aggressive suctioning (oral defensiveness)
The latter two could result in delayed stooling (not constipation). I have yet to see constipation in the normal newborn population; at least not in-hospital. If a baby gets formula instead of breastmilk s/he might eventually develop constipation, but any delay in stooling in the first few days of life is either related to inadequate intake, to narcotics for NAS, or to a more serious condition like an obstruction or Hirschsprung's. Birth stress doesn't cause constipation; if anything babies mec when distressed.
Would it be cheating to list incontinence; total?
(I'm only partly kidding; those diapers DO have to be changed!)
Good luck, and I hope you enjoyed your newbie!
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