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juan de la cruz MSN, RN, NP

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  1. Like
    juan de la cruz, MSN, RN, NP reacted to Brian S. in What’s your favorite feature with the brand new allnurses.com?   
    Thanks to everyone who commented. We truly appreciate the feedback!
    A special congratulations to @NurseBlaq, @juan de la cruz & @mtmkjr who were selected as winners! Your prize packs will be arriving soon...
  2. Like
    juan de la cruz, MSN, RN, NP got a reaction from LadyT618, ADN, MSN in 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.
  3. Like
    juan de la cruz, MSN, RN, NP got a reaction from Dean Uguan in Being Gay and a Male Nursing Student   
    After reading through the replies, a few comments caught me off guard...
    Those that said they were fine with a gay co-worker as long as he doesn't talk openly about his sexual exploits. Really? as if gay men have a predisposition to talk openly about their sexual experiences. Gay men were largely raised by parents in the same society everyone else grew up in...one that for the most part taught them a set of mores and social convention that makes it inappropriate to discuss such topics in a professional environment. The fact that some of us know nurses, gay or straight, male or female, who have exhibited said behavior has more to do with lack of manners and no particular group can claim exclusive ownership of such behavior.
    Those that said they are fine with a gay co-worker as long as they are not flamboyant. What does that even mean? Gay men are not a monochromatic group of people as many of us know. There are masculine-acting gay men on one end of the spectrum and feminine acting ones on the other end. Many fall in between both ends of that spectrum. Are we only accepting gay men on the condition that they fall closer along the masculine end of the spectrum? That's like saying I'm only a half homophobe. What about lesbians who have masculine haircuts and physiques? Are they not OK too? What about transgender nurses who are certainly part of the LGBT umbrella?
    Coming out is a process that is very difficult for all LGBT people. I give a lot of credit and respect to those who come out and are not afraid to show their LGBT colors to their family, friends, and co-workers regardless of where they are on the spectrum. Things may have changed now from 20 years ago but you are either an ally and accept all LGBT people or you don't.
  4. Like
    juan de la cruz, MSN, RN, NP got a reaction from NurseTrishBSN, RN in Nurse Charged With Homicide   
    It’s not far off to order Versed. It’s shorter acting than Ativan. Atypical antipsychotics like Haldol would be a bizarre choice for a patient who is totally alert, oriented, and only complaining of being nervous inside enclosed spaces.
  5. Like
    juan de la cruz, MSN, RN, NP got a reaction from traumaRUs, MSN, APRN in Nurse Practitioner Residencies   
    In California, one program allows FNP's in their acute care-focused programs:
    and another, within the same university system will exclusively admit AGACNP grads only:
  6. Like
    juan de la cruz, MSN, RN, NP got a reaction from Oldmahubbard in 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.
  7. Like
    juan de la cruz, MSN, RN, NP got a reaction from traumaRUs, MSN, APRN in Nurse Practitioner Residencies   
    In California, one program allows FNP's in their acute care-focused programs:
    and another, within the same university system will exclusively admit AGACNP grads only:
  8. Like
    juan de la cruz, MSN, RN, NP got a reaction from traumaRUs, MSN, APRN in 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)?
  9. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in To Hell and Back: Demons of ICU Past   
    Teresa, a woman in her 40's, a wife and mother of two young boys, felt tightness around her chest as she suddenly woke up from sleep. She was breathing heavily and bathing in a pool of sweat as she clasped her arms over her chest. She was having nightmares again. In the dark and troubling dream she was having, she was being tortured by men and women in light blue outfits. They were laughing at her, taunting her while she lay helpless in the middle of a dark alley. They were trying to suffocate her with what appears to be an oval-shaped plastic contraption covering her nose and mouth. They were trying to make her breathe air that looked like smoke. Before she knew it, her arms were tied up and she was unable to move, unable to scream for help. She was crying inside but nobody could hear her. That's when she woke up all of a sudden and sat there in the bed trying to catch her breath, her husband at her side reassuring her that it was just a dream.
    She's been having recurring bad dreams. One particular ugly scene involved being incarcerated against her will at a filthy jail. Inmates were screaming left and right. They were crying in pain but nobody listens. All she hears are laughter from the guards who should be helping the poor inmates. They were slamming glass sliding doors at her as she cried in pain. Another vision involves seeing the sad face of her two boys peeking at the glass door in her small square room but they couldn't get in. She wanted them inside so she could hug them but she couldn't. Then, at one point her husband showed up with one of the female guards, the meanest of the bunch. She had her arms around him as they both smiled at her. In her mind, there was no doubt he was having an affair with that woman. She wakes up realizing it was just a bad dream but the anger she felt in the nightmares seemed so real.
    Teresa was never a victim of a sexual assault. She has never lived in a town destroyed by a natural calamity. She was neither a war veteran nor a refugee from a war-ravaged country at any point in her life. Teresa was a patient in the ICU last year. She had a severe form of pre-eclampsia called HELLP which also led to the demise of her fetus, a baby who would have been her third child. She had a prolonged and complicated ICU stay marked by multi-organ failure. She required intubation and mechanical ventilation for respiratory failure, multiple transfusions of blood products due to bleeding from liver failure, and continuous renal replacement therapy due to kidney failure. Teresa won her battle physically, her body fought a hard fight and she recovered from all the physiologic derangements with minimal sequelae. However, she is now left psychologically scarred from the experience. She is seeing a mental health provider and is diagnosed with Post-Traumatic Stress Disorder (PTSD) as a consequence of her ICU experience.
    PTSD Among ICU Survivors: Scope and Prevalence
    All individuals who experience events perceived as traumatic undergo a cascade of emotional and physiologic reactions as the body's normal defense to stressors, a "fight or flight" reaction if you will. We all go through incredibly rough times in our lives as we live in this imperfect existence but what sets PTSD sufferers apart is that long after the experience has ended, the trauma still haunts in a profound way. PTSD affects an individual's ability to live life to the fullest by interfering with life's tasks such as employment and other roles in society we all need to fulfill.
    Symptoms of PTSD
    Re-Experiencing Symptoms include nightmares, frightening thoughts, and flashbacks Avodiance Symptoms include staying away from places or situations that remind the individual of the trauma, emotional numbness, depression, guilt, and lack of interest. Hyperarousal Symptoms include insomnia, outbursts of anger, feeling "on edge". To be diagnosed with PTSD, an individual must manifest at least 1 of each of the above symptom clusters for at least one month. PTSD is well-documented among all survivors of traumatic events particularly war veterans but a growing body of Critical Care literature is describing PTSD among survivors of an ICU stay as early as the 1980's. In 2008, Davydow et al found 19% median point prevalence of clinician-diagnosed PTSD among ICU survivors after a systematic review of fifteen studies on the topic. A more recent longitudinal study by the same primary investigator published in 2012, found the prevalence of substantial PTSD and depressive symptoms were 16% and 31% at 3 months post-ICU and 15% and 17% at 12 months post-ICU respectively.
    Who Are at Risk?
    Multiple studies have tried to identify which of the individuals who had an ICU admission are more likely to suffer from PTSD later. A small study by Girard et al in 2007 published in Critical Care found high levels of PTSD symptoms in patients following critical illness necessitating mechanical ventilation and that these symptoms were more likely to occur in females who received high doses of Lorazepam. Older patients, they found, were less likely to have PTSD.
    The previously mentioned review by Davydow et al in 2008, however, had more extensive findings. His group's research found that consistent predictors of post-ICU PTSD are pre-ICU psychopathology, greater ICU benzodiazepine administration, and post-ICU memories of in-ICU frightening and or/psychotic experiences. Interestingly, his group found that female sex, younger age, and severity of critical illness were less consistent predictors of post-ICU PTSD. He also found that the duration of mechanical ventilation and length of ICU stay has little evidence to support the later occurrence of post-ICU PTSD.
    Hope: Our Role as Nurses
    As Critical Care Nurses, we are proud of being thorough and for looking out for the whole patient from head to toe. We clock a great deal of patient care time at the bedside, more than any other healthcare professionals who see patients in the ICU. Thus, we hold the key to advocating for patients' rights to be free from harm intentional or not.
    A great deal of post-ICU PTSD sufferers appear to be younger with a pre-existing psychopathology prior to the ICU admission. However, knowing these risk factors is only half the battle. The literature on post-ICU PTSD recommends screening of patients after an ICU stay as a way to make sure that patients at risk are identified and future referrals for counselling and mental health assistance are provided in order to assure a recovery that is whole, one that involves wellness of mind and body.
    We know that ICU patient management involves a lot of frightening, painful, isolating, and traumatizing events. These are unavoidable because they are part of the patient's treatment in order to get better. Involving the patient and his/her family in our thoughts and planning by preparing them in a manner that is least intrusive to their well-being could make a big difference in how the ICU experience is perceived later.
    A growing movement in Critical Care Nursing is the use of ICU Diaries. These have been introduced in European ICU's initially but have slowly but surely reached our US soil. ICU Diaries are written accounts by family members, nurses, and providers during a time when the patient is unable to understand or comprehend his/her physical surroundings while sedated and/or mechanically ventilated.
    The Diary allows for unlimited creativity. Not only are events of the day easily transcribed to add a reality-based affirmation of the ICU stay to the patient who could read it later during recovery but messages of support, prayers, and love are a way for family members and friends to extend a connection to the patient who is unable to interact at the time. Pictures can also be posted and serve as a reminder of what is real and happening at the time. ICU Diaries have been studied in the Critical Care literature as well and have been shown to be favorable to patient recovery later.
    Please share your thoughts and experiences and don't forget to check out the following links:
    ICU Diaries
  10. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in Solve A Neurologic Mystery   
    Background / Social History
    RS is a 70 year old, lady who lives independently in a first floor apartment in the city. She has no close relatives but has neighbors who know her very well and check in on her from time to time. She hires a cleaning lady that does her house cleaning and laundry every week. Her nearest relative is a niece who lives in the same state but is 8 hours away by car.
    Past History
    Her medical history includes anxiety disorder, hypertension, hyperlipidemia, COPD, and mild kidney insufficiency.
    She has a 40 pack/year history of smoking.
    She has no known allergies.
    She takes the following medications: Paroxetine 20 mg daily, Lorazepam 1 mg daily as needed for anxiety, Losartan 100 mg daily, Amlodipine 10 mg daily, Simvastatin 40 mg daily, Tiotropium 18 mcg inhaled daily, and Albuterol MDI 2 puffs 4 times a day as needed.
    Present History / CC
    On the day of her ED admission, her niece had been calling her phone and had been unable to get hold of her. Her niece called a neighbor who stated that she has not seen RS in 3 days. Concerned about RS's condition, the neighbor knocked on her door and heard no response. Luckily she was able to open the door as it was unlocked. Upon entering the living room, the neighbor found RS lying unconscious on the floor. She had frothy secretions from her mouth and had urinated on herself. She immediately called 911. She was intubated at the scene by EMS responders for airway protection due to her altered mental status. Her VS were: BP 180/100, HR 110, RR 32, T 38.5 C, O2sat 88% on RA prior to intubation.
    Diagnostic Studies
    In the ED, RS pertinent labs showed a WBC of 15,000 mm3, a lactate of 2.5 mmol/L, and CPK of 20,000 U/L. Neurologic exam was significant for agitation and inability to follow commands with sedation wean. She was hyperreflexic with increased muscle tone. She is moving all her extremities equally and has no abnormal pupillary response. She is sedated on Propofol. CV exam reveals sinus tachycardia with BP of 110/50, her skin is warm to touch. Respiratory exam reveals rhonchi in upper lung fields with moderate white secretions via ET tube, ABG: 7.36, 38, 82, 19, -3, 100% on ACVC: 16X400, FiO2 of 0.5 PEEP of 5. CXR reveals mild cardiomegaly, a hyperinflated lung silhouette and mild RLL opacity. Non-contrast CT Scan of her brain showed focal vasogenic edema in the basal ganglia. The rest of the exam revealed normal findings.
    The ED was particularly busy that evening so RS was immediately transferred out to ICU without further testing in the ED. Because of her complex medical condition, she was transferred to the MICU under your care as her primary RN. What thoughts run in your head that could possibly explain what caused RS's presentation? What further testing would you anticipate? How would you care for RS as her nurse?
    For this exercise to be fun and informative, answer in the following manner:
    List possible explanations you would expect to hear from her medical team that could explain her neurologic presentation and why. Tests you would anticipate. Interventions you would provide as the bedside nurse and why. Note: this is an actual case and the outcome is already established.
  11. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in Doctor of Nursing Practice (DNP): My Personal Pro's and Con's   
    The Doctor of Nursing Practice or DNP degree has been one of the biggest buzzwords in Advanced Practice Nursing. The mere mention of it creates a stir of emotions and strong opposing opinions perhaps of the same magnitude as the liberal versus conservative views prevalent in our current political climate. Unlike nursing buzzwords that come and go depending on what is en vogue at the moment, current Advanced Practice Nurses (APN's) who hold stronger feelings of opposition rather than agreement with the degree would be foolish to ignore the issue. There are strong indicators that support the argument that this degree is here for good.
    For one, Advanced Practice Nursing while a smaller subgroup within the larger nursing milieu has shown tremendous ability to self-regulate and adapt to change. Indeed, the speed at which change have occurred in the APN environment is astonishing. The Nurse Practitioner movement, for instance, borne out of an idea in the 1960's, have now blossomed into a membership of more than 180,000 professionals (Pearson Report, 2011). In that period of time, Nurse Practitioner (NP) training completely transitioned to post-licensure nursing programs leading to a certificate to the current graduate degree offerings at the Master's and Doctoral level. The Centers for Medicare and Medicaid Services (CMS) have even kept up with this change and will only grant provider status to NP's who are trained in a graduate degree program.
    One can argue that the number of DNP programs have consistently grown in numbers since the first discussion on building a practice doctorate in nursing began in 2002. The American Association of Colleges of Nursing (AACN) lists 139 institutions with DNP programs around the country, roughly 20% of the total number of member institutions totaling 670 (AACN Program List). Twenty percent may seem small but bear in mind that not all AACN member institutions are offering graduate-level programs that have a potential to be transitioned to DNP. Also, the current program list does not include online DNP programs offered by for-profit institutions that have various locations in different states of jurisdiction. My take home message from these data is that while the recommendation for making the DNP a requirement for entry to practice as an APN is farther from becoming a reality by 2015, the pace at which programs are opening up will continue and the degree is here to stay whether we like it or not.
    The DNP was just an idea when I finished my training as an Acute Care Nurse Practitioner (ACNP) in 2003. At the time, academic options were clear to me: pursue a Master's degree with my preferred nurse practitioner focus; get certified in the specialty, and voila, I am all set to practice as an ACNP. The option for further academic advancement at the Doctoral level was also very clear: the next step is a PhD or a DNSc both of which have become identical in content. In fact, numerous faculty members encouraged us to consider returning to the halls of the same university (or maybe even another institution) as a PhD student at some point in our career. The idea had a glamorous appeal to it in my mind at the time and I did entertain the thought of following through. Even to this day, I still struggle with the idea and have not come to a conclusion on what the right Doctoral education path to take. What's worse, this whole DNP agenda threw a curveball in my decision-making process.
    As an Acute Care Nurse Practitioner since 2004, I have matured and continue to grow professionally in my knowledge and skills as a clinician. I have stayed in the field of Critical Care as an NP since 2005 and have felt this to be my niche early in my career. In my personal quest both for academic advancement and to grow as a healthcare provider, I do not share the sentiments that the ideal MSN to DNP Bridge should be loaded with clinical content by adding so called "residencies". Don't get me wrong, I feel strongly that clinical content could undeniably be improved in the current manifestations of BSN to MSN or BSN to DNP programs for NP's. But I'm being selfish in my personal goals: since I already practice in a heavily patient care-based setting where knowledge and skills already get tested daily, my needs are different. In other words, I do not need a DNP to get a "residency" in Critical Care because I live and breathe in this specialty day in and day out.
    DNP courses that deal with leadership, management, the politics of healthcare, and the financial aspect of providing healthcare can be appealing to individuals in my professional level. This is the reason why there already exist multidisciplinary degree options outside of nursing that addressed this content even before the DNP was conceived. I remember a Cardiothoracic Surgeon I knew who went to a prestigious graduate school of business for a Master's degree in Healthcare Administration. The guy had big dreams of being a division chief or a CEO. A nurse manager in one of the units pursued a Master's degree in Nursing Service Administration because she had high hopes of climbing the ladder ultimately as a Chief Nursing Officer one day. Though I consider myself a clinician foremost, a business degree is a must should I decide to pursue a role in administration. That said, I do not think a DNP is necessary if I was to pursue this direction in my career given the other degree options that already exist.
    It seems to me like the DNP marketing machine has been trying to convince NP's like me to think that we need a DNP in order to learn from courses that focus on translating research evidence into clinical practice. I find this to be untrue and insulting to currently practicing NP's trained under the Master's degree model who use evidence-based practice in providing care to their patients every day. However, a Capstone Project utilizing Translational Research is a great idea in itself and though such an activity can be accomplished outside of academia, the DNP student who conducts this endeavor is provided with structure and mentoring from experts in any field of inquiry they are interested in. This particular aspect of the DNP convinces me of the value in getting this degree.
    The last argument I have been trying to contend with is the DNP's future in terms level of acceptance in academic roles in schools and colleges of nursing. There has not been a straight answer on how universities determine academic ranking for DNP-prepared faculty as this continue to vary depending on the institution. In the years I've been at the bedside as a nurse and as an Advanced Practice Nurse, I have acquired a great deal of past experiences and lessons learned that are worthy of being passed on to new generations of nurses who wish to follow the path I took. A role in the academia, though not attractive at the present given the low earning potential, is inevitable in my future. However, I seek assurance that the degree I pursue is held at the highest regard in terms of advancement in the field of nursing education. It is still tempting to forego the DNP for the much respected PhD in Nursing.
  12. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in Case Study: Fever   
    It depends on the indication.
    In this case, the patient will remain intubated with as minimum vent settings as possible while ECMO does the work of providing oxygenation/ventilation and circulation/perfusion. Think of it as a portable cardiopulmonary bypass machine that is used in the OR for open heart surgery cases. As the ECMO settings are weaned, the patient is gradually taken off from ECMO support with the goal of decannulation. The patient then remains on the vent until extubation.
    In some centers, ECMO has been used as a bridge to lung transplantation. Patients who are lung transplant candidates MUST maintain a certain degree of mobility preceding transplantation. Those who decompensate with escalated oxygen requirements unable to be delivered with conventional non-invasive methods (i.e, high flow) are actually intubated, cannulated on ECMO, extubated and allowed to get out of bed (on ECMO!) - in that order while waiting for a lung donor.
  13. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in Case Study: Fever   
    OK guys time for the update:
    So Rolando was hypotensive after intubation. You guys are right that the Propofol contributed to the drop in his blood pressure. However, many times patients who are in respiratory distress have a surge of catecholamines which artificially increases their blood pressure and once you knock off the offending stimuli (respiratory distress), the blood pressure tanks. Rolando was actually started on pressors.
    The ED continued to struggle with profound hypoxemia and transferred him to the ICU at the community hospital where his subsequent CXR showed worsening bilateral fluffy infiltrates. His pO2 remained low and he started having hypercarbia as well. He quickly presented with a septic picture and was on high doses of Norepinephrine. The community hospital decided that Rolando was too sick to be cared for in that setting and called the nearest tertiary facility for higher level of care.
    That's when we started taking care of him. Our facility has an ECMO program. Rolando was cannulated for Veno-Arterial Extracorporeal Circulatory Life Support. He was in multi-organ failure involving his circulatory system (distributive shock), respiratory system (hypoxemic and hypercarbic respiratory failure due to acute lung injury from infection requiring ECLS), and renal (acute kidney injury from acute tubular necrosis requiring continuous renal replacement therapy with CVVHD).
    The community hospital updated us of his culture results: as many of you suspected, his respiratory secretions grew Coccidiodes spp. He had Valley Fever which has progressed to Disseminated Coccidiomycosis. Valley Fever is caused by a fungus of the Coccidiodes genus.
    A note about Coccidial Infection:
    - the organism that causes this disease is endemic to Southern Arizona, Southern and Central Valleys of California, Southwestern New Mexico, and Western Texas.
    - infectious manifestations vary from very mild to severe disseminated pulmonary and extrapulmonary disease. Immunocompromised hosts are at high risk for severe infections (those with HIV, transplant recipients on immunosuppressive therapy, patient on chemotherapy, etc).
    - there are reports that people of Native American, African, and Philippine descent tend to present with severe cases. A study in California, however, did not support the evidence that people of Asian (Philippine) and Hispanic racial or ethnic background are at risk for severe cases (see link)
    - treatment with antifungals such as Fluconazole and Itraconazole are recommended. Amphothericin B may be considered in severe cases with the caveat that toxicity can be problematic. Newer antifungals such as Voriconazole or Posaconazole have not been well studied on its effectiveness in Coccidiomycosis.
    Rolando's Hospital Course:
    Perhaps owing to his healthy state prior to his infection and his age, Rolando improved clinically on ECLS and was eventually decannulated from the bulky device. He was eventually taken off pressors as well. He remained on intermittent dialysis for a period of time but subsequently had return of his kidney function. He luckily did not require a tracheotomy as his neurologic status was unaffected (his CSF was negative for cocci) and was extubated as soon as his ventilatory settings were down to minimum support.
    He was transferred to a regular hospital floor after about a couple weeks in the ICU. He went home with his mother after his hospital stay.
  14. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in Case Study: Fever   
    ABG's give a lot of information. Acid-base balance is one. It also lets us know how adequate oxygenation and ventilation are. In the initial ABG, the pH is 7.40 which is in the middle (range is 7.35-7.45), bicarbonate is not really low so no metabolic component. PCO2 tells us about ventilation which 37 is within normal. Many posters already alluded to the profound hypoxemia (low PO2).
  15. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in Case Study: Fever   
    Rolando was appropriately triaged as emergent and was placed on Airborne Precautions in negative room pressure. The triage nurse appropriately secured an order for high flow nasal cannula. You are now his nurse in the ED.
    Orders were for:
    Respiratory Viral Panel, Sputum bacterial and gram stain, Legionella serum Ab, Pneumococcal serum Ag, Sputum for AFB. You were able to send all the appropriate specimens for these tests.
    You were also asked to obtain ABG with lactate, CBC, Basic Metabolic Panel, and Coagulation Studies. Blood cultures were ordered. UA with tox screen was also ordered.
    A portable CXR was obtained.
    Available labs revealed:
    Ph 7.40 pCO2 37 pO2 56 HCO2 22 BE 0 Sat 90% Lactate 2.5 on HF at 100% FiO2


    WBC 18,000 Hgb 16 Hct 48 Plt 300 (+) Eosinophilia
    Na: 140 K 4.0 Cl 100 CO2 22 BUN 15 Crea 0.5 Gluc 87
    PT 14 INR 1.1 PTT 23
    negative for UTI or drugs

    Rolando is working a bit harder to breathe after 1 hour of being under your care. What would you anticipate next?
  16. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in Case Study: Fever   
    The following is a case involving a young male who presents with fever associated with respiratory symptoms. This is based on a real case. The events leading to his hospitalization and his course in the hospital will be portrayed in an attempt to stimulate discussion on ways to approach his care not only from a nursing standpoint but also to understand the complexity of his care from the perspective of other disciplines who will be involved in his care particularly his medical management.
    Background History
    Rolando is a 19-year old college student who is the son of first generation immigrants from the Philippines. His parents are divorced and he lives with his mother in a coastal town close to where he attends college. He decided to skip the fall semester and live with his father in California's Central Valley region to help him run a small business.
    He presented to his family physician with complaints of productive cough for about 7 days and feeling warm and flushed. He said his phlegm looked white in color and not excessive. He appeared healthy and has no medical history other than having had his appendix removed at age 14. The physician prescribed him Azithromycin and cautioned him to seek further care if his symptoms do not improve. He recalls having some tests done at the clinic but was not sure what they were.
    Three days later, Rolando was feeling worse. He feels he is warmer and may have a high fever, is having chest discomfort with coughing while not expectorating any phlegm, and is experiencing joint pains and muscle aches. He has no appetite and is feeling weaker. His father was concerned and brought him to the nearest ED at a community hospital setting.
    Social History
    His social history is notable for being a college student with an undecided major. He admits to drinking alcohol occasionally but denies binge drinking, he does not smoke, he admits to having smoked marijuana in the past but not recently. He has a girlfriend in college and is sexually active.
    You are Rolando's first contact in the ED as the triage nurse.
    After gathering the above, you obtained the following data
    Subjective complaints: "feeling warm, headache, little short of breath". Temperature 39 C, HR 112, RR 32, BP 110/65, O2Sat 88% on room air Neuro: AOx3, moving all extremities, pupils equal and reactive. CV: EKG showed Sinus Tachycardia with no ST changes, no murmurs were heard on auscultation, no edema in extremities. Pulm: Harsh breath sounds bilaterally but no accessory muscle use. He does breathe fast as you noted in his respiratory rate. Skin: Warm and flushed, you notice what looks like a red rash in his bilateral shins. Rest of the system exam is WNL. Questions
    How would you triage Rolando and what tests would you expect to be done in his case? What would you tell the next ED nurse who will take care of Rolando once you determined the appropriate ED treatment area he should be treated at? What concerns do you have about what is likely the reason for his symptoms?
  17. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in "A Case of Bad Blood"   
    Case Study
    CJ is a 65-year old female who tripped and fell inside her home landing on her right side. She felt immediate excruciating pain in her R hip and couldn't manage to get herself off the floor. Fortunately, she had a mobile phone in her housecoat pocket and she was able to call her son who arrived in her home within ten minutes. She was taken by ambulance to the ED where an x-ray revealed that she had sustained a hip fracture. CJ is otherwise healthy aside from a medical history that is notable for HTN and hyperlipidemia that are adequately managed with oral medications.
    CJ was seen by an Orthopedic Surgeon who recommended surgical intervention to repair her fractured hip. She was cleared medically to undergo surgery. CJ was taken to the OR for an ORIF and was intubated for general anesthesia. She had significant blood loss from the surgical procedure and required blood transfusions during the case. At the conclusion of her 3-hour surgical procedure, she had received 3 Units of PRBC's. Additional 2 Units of FFP's were ordered because her surgical drain had significant output. CJ was transferred to the ICU intubated because she was slow to wake up from anesthesia. The nurse received report from the Anesthesiologist that CJ already received the first unit of FFP and the second unit is half-way transfused.
    After receiving the second unit of FFP, her nurse noted an acute onset of oxygen desaturation to 75% and tachycardia. She was triggering the high peak airway pressure alarm on her ventilator. The nurse and respiratory therapist noticed copious amounts of pink, frothy secretions coming out of her oral endotracheal tube. Her FiO2 and PEEP were increased to 100% and 10 cmH2O respectively in order to maintain oxygen saturations above 90%. Chest x-ray was immediately obtained and showed bilateral pulmonary infiltrates with a normal cardio-mediastinal silhouette.
    The Intensivist is concerned that CJ suffered a Transfusion Related Acute Lung Injury or TRALI.
    As nurses working in critical care, transfusing blood products is a common role we perform. While blood product transfusion reactions come in many forms, a distinct type of blood product transfusion reaction known as TRALI is a rare but life-threatening condition that we must be aware of because it is the leading cause of transfusion-related mortality described in the range of 40-60%. The true incidence of TRALI is difficult to estimate not only because cases of TRALI are under-reported but also because of previous disagreements among clinicians as to which cases meet the criteria for this diagnosis.
    The exact mechanism of TRALI is not well understood, however, experts accept the two-hit mechanism which involves:
    Neutrophil sequestration and priming - patient has intrinsic condition that causes neutrophil sequestration and priming in the lung microvasculature. This happens before the blood transfusion. Neutrophil activation - when patient receives blood product, factors present in the blood product causes the recipient's neutrophils to release cytokines that damage the lung microvasculature leading to pulmonary edema. Neutrophil Activation Can Happen in Two Ways
    Immune mediated - via anti-HLA antibodies and anti-HNA antibodies in the donor blood Biological response - biologically active lipids present in WBC's, platelets, and red blood cell breakdown. TRALI Diagnostic Criteria
    In an effort to standardize this clinical diagnosis, a consensus by the National Heart Lung and Blood Institute of the National Institutes of Health defines TRALI as new acute lung injury (ALI) or ARDS occurring during or within six hours of blood product administration.
    Conventional criteria for the diagnosis of ALI/ARDS as defined by the Berlin Criteria
    Acute onset Bilateral infiltrates on chest x-ray PaO2 to FiO2 ratio (P/F ratio) less than 300 with a minimum PEEP of 5 cmH2O Etiology must not be fully explained by cardiac failure of fluid volume overload Possible TRALI
    The above clinical diagnosis is made using strict criteria that only implicates the blood product transfusion as the culprit in the development of ALI/ARDS. In cases where the development of ALI/ARDS coincide with blood product transfusion but other confounding events exist such as aspiration, infection, or trauma, then a diagnosis of Possible TRALI is preferred.
    A similar presentation of transfusion related respiratory insufficiency is Transfusion-Associated Circulatory Overload or TACO. In order to distinguish from TRALI, TACO is associated with rapid blood product administration in the setting of fluid volume overload and compromised cardiac function. The mechanism for pulmonary edema is of a hydrostatic process in nature, that is, elevated pressures in the pulmonary circulation causes fluid to shift to the extravascular space into the lung parenchyma.
    Nursing Care Planning
    Nursing diagnoses that may apply to TRALI include:
    Impaired Gas Exchange related to alveolar fluid accumulation as evidenced by dependence on mechanical ventilation with increased oxygen and PEEP requirements. Anxiety related to difficulty breathing and increased respiratory effort as evidenced by inability to maintain adequate oxygen saturation without mechanical ventilator assistance. Treatment
    Treatment for TRALI is supportive. Transfusion should be stopped immediately if TRALI is suspected. Follow your facility protocol in terms of triggering blood bank evaluation of a transfusion reaction. It is important that cases of TRALI are reported and confirmed to protect future recipients of the donor blood. In many cases, patients are profoundly hypoxemic enough to require intubation and mechanical ventilation.
    Traditional ARDS ventilatory strategies are employed. Hemodynamic monitoring is indicated as some patients develop hypotension and must be supported with fluid resuscitation and/or vasopressors. Education and emotional support to patients and families are important. The clinical course of TRALI has been described as short with quick resolution in mild cases to as long as 40 hours in severe cases though longer periods have been reported.
    It should be noted that cases of TRALI have declined significantly in recent years due to efforts at prevention. Blood donors implicated in TRALI cases should be deferred from future blood donation. Also recall that the mechanism thought to trigger TRALI partly involves immune mediated antibodies present in the donor blood particularly anti-HLA and anti-HNA antibodies. Some specialty laboratories in the US have the capability for neutrophil antibody testing to detect the risk of reaction from donor to recipient though this testing is expensive and still not widespread.
    More importantly, blood products donated from multiparous women and individuals who received multiple blood transfusions in the past have been found to contain the antibodies implicated in TRALI. As a consequence of this finding, most centers preferentially obtain blood products from male donors and screen female donors in order to eliminate the possibility of donation by multiparous women and individuals who has a history of receiving multiple blood transfusions. Lastly, blood transfusions must be utilized with reasonable indication and with thorough consideration of its risks.
    Further Reading
    Transfusion medicinel
    Transfusion-related acute lung injury surveillance (2003-2005) and the potential impact of the selective use of plasma from male donors in the American Red Cross
    [PDF] TRALI Risk Mitigation for Plasma and Whole Blood for Allogeneic Transfusion
    AABB (formerly American Association of Blood Banks) Bulletin
  18. Like
    juan de la cruz, MSN, RN, NP got a reaction from sirI, MSN, APRN, NP in "A Case of Bad Blood"   
    Thanks guys, I altered the clinical case a bit in this scenario to make the story more clear. The patient who inspired me to write the case did well and was discharged from the ICU and eventually to a rehab facility. She was on the mechanical ventilator for 4 days.
  19. Like
    juan de la cruz, MSN, RN, NP got a reaction from Oldmahubbard in 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.
  20. Like
    juan de la cruz, MSN, RN, NP got a reaction from traumaRUs, MSN, APRN in 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)?
  21. Like
    juan de la cruz, MSN, RN, NP reacted to ArmaniX, MSN, APRN in NP still working as a bedside nurse on the side...   
    Can’t ever lose those critical acute care skills! Just like we kept those flash cards from Nursing Fundamentals 1. 🙄
    I’d invest your time and energy into your soon new career path. You won’t need to know how to run a CRRT machine or push adenosine as an FNP. There is no need to continue to maintain a set of skills that hold little value in your day to day. Let them go, enjoy all the new responsibilities and duties that are about to be sitting at your feet. 
  22. Like
    juan de la cruz, MSN, RN, NP reacted to NPfellow123 in NP Fellowship experience   
    Hi Everyone, 
    I am writing a post I wish I could have found online a year ago when I was trying to decide how to start my career as a new nurse practitioner. I am in a fairly prestigious NP Fellowship program in NYC and I do not recommend it. Be very cautious with your expectations and who you talk to if you are looking into programs like these. Ask to speak with fellows or former fellows who are not the people the company first recommends. Ask very specific questions such as, what kinds of concerns have current fellows expressed, and how many of the fellows have expressed any concern about the program. If there is something that is important to you to get out of doing a fellowship or residency, don't be scared to ask about it in great detail in the interview and if you get an offer. Ask them and pursue getting a clear answer. Ask how many fellows have gotten to do the procedures you care about doing or how often fellows see patients in specific populations if that motivates you (peds, newborns, obstetrics) and ask for very specific percentages. Ask about who the preceptors are and how often fellows are not precepted in person by someone who has experience working for the organization when they are supposed to be precepted. Ask about what any "independent" clinic time means, for example, ask if it means that fellows will be completely on their own from day 1 of practice during independent clinic with no clinician available for even on site EMR assistance or training. Beware of vague answers. This program has not done a lot of the basic stuff it promised us, and has done a lot of additional things that have been terrible. A lot, if not most, of the people here this year are very unhappy. Perhaps the most general advice that I can make based on my group of fellows is, if you have a job offer that appeals to you even somewhat and you are weighing it against a fellowship opportunity, I encourage you to take the job offer. Don't make sacrifices to do a fellowship that you hope/believe will be a great opportunity unless you have really good insight into the program, like a friend who went through it and gave you the real scoop. Fellowships and residencies are great ideas and we need them badly but there aren't a lot of resources to support them, and at least in my company it is basically a disaster. I wish I had asked a lot more specific questions beforehand. Ask to get in writing the things that the fellowship will do that are important to you (even basic things like precepted hours, the ratio of preceptor to fellows- (it's not going to be 1:1), and the definition of precepting- it should not be done by phone "as needed"). I would also get the maximum patient numbers in writing if the program is increasing patient numbers over time. 
    I've never posted on this website before, but I always read it before making big career decisions. Sometimes I found helpful info and sometimes I didn't find much. I hope this can be helpful to someone else like me. 
  23. Like
    juan de la cruz, MSN, RN, NP got a reaction from Oldmahubbard in 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.
  24. Like
    juan de la cruz, MSN, RN, NP got a reaction from deltadiva_RN in UPenn Streamlined Post Masters Acute Care   
    I work with two NP's who already completed the program. I know another one who is currently enrolled. They are all working in acute care as NP's and are allowed to use their work hours for clinicals by logging in their work hours. The didactics were all online.
  25. Like
    juan de la cruz, MSN, RN, NP got a reaction from coffee&scrubs in Dual DNP/PhD programs: what's most important?   
    I think many nursing schools doesn’t have the structure that allows nurses to split clinical time between research and academia. Many times, our medical centers are too detached from the nursing school. Many of our PhD faculty have not been at the bedside for years. Medicine doesn’t typically operate like that. As an employee of an academic medical center, it is expected that our attending physicians have appointments in the medical school as faculty and many juggle clinical time with a research lab. Even the ones on the top of the hierarchy. In fact, physicians don’t need an MD/PhD to serve as primary investigators.