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juan de la cruz MSN, RN, NP

Adult Critical Care Nurse Practitioner
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  1. juan de la cruz

    Moving from LTC to the hospital

    I went from working in acute care as a nurse in a foreign country to LTC when I immigrated to the US. That was the only option I had at the time but I stayed for about three years until I could transition back to a telemetry unit. This was in the 90's. It was tough getting used to the 12-hr shift but I didn't have a hard time managing my time since I actually had less patients than in LTC. I also felt that some of the nurses underestimated my abilities and focused on my recent LTC experience until they realized I worked as a nurse in a hospital in a foreign country where I was proficient in starting IV's.
  2. juan de la cruz

    NP Fellowship experience

    Would you be able to specify what type of NP you are (FNP, AGACNP, etc) and what this fellowship program was for (i.e., Family Practice)?
  3. juan de la cruz

    Giving up PA school acceptance to pursue ASN?

    That’s a decision that you as a family should decide. It’s a 2-year sacrifice and a student loan that will not go away for a while. Nursing does offer many options but they are not always appealing compared to a provider role in my opinion. But I’ve been an NP for many years and I will admit that there are jobs and hospitals in my area I would not hate working in as an RN. That said, we have a saturated RN pool here and an ASN is not enough to get you a nice RN job.
  4. juan de la cruz

    Medical marijuana

    I'm in California where medicinal use cannabis has been legal for many years so there are many established practices both online and in person that advertise as a "consultation" service specific for medicinal cannabis use. Now that the state also legalized recreational marijuana use, I am hearing that there is a decrease in demand for these "consultations". The public is still advised that the amount of marijuana you could purchase for recreational use is less than what you would be able to acquire or even grow if one were to carry a medical marijuana card. I would be weary of joining an online evaluation service in California. The websites do not appear professional and there are no listings of the credentials of the providers. Besides, there are many long-standing providers in the state with their own primary care practice who have lots of years of experience with patients who use cannabis for medicinal purpose and many actually work with NP's. I would be more inclined to join such a practice if this is your interest. However, I'm a hospital based NP who rarely if at all discharge patients to the community and don't address primary care in my practice so I have no interest in this aspect of care at all.
  5. juan de la cruz

    Interview advice

    Can you call the recruiter and ask? or maybe someone in HR can tell you his/her name.
  6. juan de la cruz

    Can't get ACNP job

    @core0, how competitive are those fellowships? I ask because we have one too but it is quite competitive and grads of our AGACNP programs will get preference as well.
  7. juan de la cruz

    NTI 2019 - "Education, Excellence and Inspiration"

    There is an attendee roster in the My NTI website where messages can be sent to each attendee. We can use the PM function here too?
  8. juan de la cruz

    What credentials do I use?

    Do you have your state license yet? Usually, the state designation is preferred in clinical documentation. In varies by state from NP to CNP to CRNP, etc. I wouldn't include any NP in your signature if you're working as an RN. I guess you could sign MSN, RN.
  9. juan de la cruz

    OMG 🤢🤢🤢

    That's reassuring @JenMH88RN, even though gastric contents seem gross, the pH is usually less than 3, enough to inhibit the growth of bacteria .
  10. juan de la cruz

    Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

    It's actually hard to come up with a solution. All drugs have a potential to be lethal if used the wrong way. A paralytic was used the wrong way now, who knows what's going to be next. Paralytics in particular have been a culprit in a lot of cases. The Institute of Safe Medication Practices claims in one of their releases that they've received over 100 reports of accidental NMB administration, 100!...it's been in their Targeted Medication Safety Best Practices for Hospitals for years. I didn't even realize that in 2014, a case of medication error involving a paralytic led to a death but this time it's a Pharmacy worker that made the deadly mistake. No criminal charges filed like the nurse in Florida in 2011: https://www.uniondemocrat.com/newsroomstafflist/4925221-151/st-charles-dropped-med-check-system-before-patients. In my mind, criminal charges or not, this can somehow become a means of "natural selection"...nature's way of separating those who've made these egregious errors from ever returning to clinical practice whether we agree with it or not. I wish there is a single trait that those who commit serious mistakes have in common other than being careless in that moment when everything mattered. That way we can identify these individuals who actually probably need serious work accommodations before someone dies in their hands.
  11. juan de la cruz

    phenobarbital for ETOH withdrawal

    I work for an institution that uses CIWA monitoring with the traditional benzodiazepine-based treatment algorithm. Our CIWA protocols are always initiated in the ICU after an ED admission if a patient is deemed a candidate for CIWA. The frequency of CIWA scoring and the amount of benzo's that may be required coupled with the risk of respiratory depression along with it led to a decision that the treatment is too labor-intensive for our floor nurses per our policy. Although I'm more familiar with CIWA protocol, once in a while we do have new fellows who trained somewhere else and are advocating for a Phenobarbital based algorithm and swear by how this had better outcomes in their own experience. We've tried it on a few patients but I haven't seen enough cases of Phenobarbital algorithm for comparison to form my own opinion. If you search online and based on what I know, initiation of Phenobarbital algorithm requires determination right in the ED when the patient presents with symptoms of withdrawal. The protocols typically ask for an IV loading dose if the patient meets criteria for Phenobarbital treatment with succeeding doses once patient is admitted. I doubt if your institution will allow such a loading dose in IV form in a cardiac floor but you'll have to check your hospital's policy on that. Phenobarbital is also a respiratory depressant like benzo's so a heightened level of monitoring is required and your Cardiac floor may be unable to offer that. Most of what I can find on Phenobarbital algorithm are in the Emergency Medicine and Critical Care literature which leads me to believe that these are done in the ICU. However, there is a review article discussing Phenobarbital use in non-ICU settings here: https://link.springer.com/article/10.1007/s40267-018-0523-1 (You'll have to pay to get the article). There is a good explanation of the comparison of the two algorithms presented by an EM/Critical Care MD here that also goes over the dosing: https://emcrit.org/pulmcrit/phenobarbital-monotherapy-for-alcohol-withdrawal-simplicity-and-power/ Finally, unlike our institution, OSU seems to protocolize both algorithms depending on patient presentation and inclusion criteria: https://evidencebasedpractice.osumc.edu/Documents/Guidelines/AlcoholWithdrawal.pdf
  12. juan de la cruz

    Can't get ACNP job

    Let's start with looking at your experience as an RN and what sort of jobs you've applied for. I agree with reaching out to UPenn, we have some of their grads where I work and they do get emails from other alumni asking for leads as far as jobs. You may have to look out of state as stated above. If you are competing with many Emory grads, it's not unusual for local grads to be preferred.
  13. juan de la cruz

    do you think your school prepared you or

    I would consider the sources of those articles. Those comments seem par for the course at SDN and in articles that want to slow down the pace of full practice independence for all NP's. My program was over 10 years ago...much of what I know now are no longer because of that program. When I was a new NP, I felt like an intern. I knew how to assess a patient, write an H&P and progress note, and present my plan to a physician. However, my plan was never final, needed some tweaking, and additional questions answered by the physician I was working with. But I certainly wasn't viewed by the practice as inept. My RN experience helped as far as modeling provider behavior and critical thinking process. As a bedside nurse, I often asked the providers about the rationale for their actions as a way to learn. I think letting go of the RN mentality can be hard when you're in a provider role.
  14. juan de la cruz

    Practicing NP, keep CCRN?

    In our group of ICU NP's less than a handful kept their CCRN certification. I am one of the ones who did but I'm active with AACN and I appreciate that organization's contribution to ICU Nursing. I think your experience as an ICU NP will carry more weight. Some physicians don't know what CCRN means.
  15. juan de la cruz

    Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

    Oh I know...a reasonable person would have told themselves "I am overriding this medication but I better be darn sure I got the right one out of the bin by triple checking the label"...then she reconstituted it without reading the label. She is an ICU nurse who must have given Versed before, wouldn't it become second nature at this point to register in her brain that Versed doesn't come out in that form? I obviously don't know how the mysteries of the human mind work. The error made by the nurse in Wisconsin who was criminally charged was that she picked the wrong one of two identical-looking IV piggyback medications that was laying side by side on a surface...she was also an experienced nurse and not a rookie like RV. I can kind of see that sort of mistake happening to me if I wasn't careful but RV's series of missteps? it's beyond comprehension.
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