cjcalimer

We discovered our last semester that our instructors has been snagging test questions from various review books on our tests all along. Makes me wish I had bought them sooner. I just took and passed my boards, and honestly I was unimpressed with their similarity to actual board questions. I used Leik and Fitzgerald books cover to cover about 10 days before my test. It was a spur of the moment decision. The review books were much more intense, picky, and difficult than the certification exam. I almost think they're better for reviewing and reference once you're in clinical then they are for study prep.

Exactly this!! Also consider how much (if at all) you might want to work during the program and how flexible your work schedule is. I worked full time while working on my MSN part time because my hospital paid a good chunk of my tuition this way (don't turn down nearly free education!). My program was a hybrid, with the last year of clinical rotation requiring weekly in class visits. My job and my coworkers mercy and generosity towards my scheduling needs would never have extended longer than that. So the fact that the preceding classes were mostly if not entirely online made that possible. Don't count on self-scheduling to make it possible for you to have every Tuesday evening free for three years or something.

You need to contact your BON and consult with your lawyer about the legal implications of testing without disclosing this information.

I've recently passed my boards (yay!), gotten my liscense, and started the process of applications and interviews. One question that came up that I felt like I had a lame answer for was about the differences between NPs and PAs. The practice I was interviewing at generally hires PAs (it's mostly surgical so that would be a factor, but this would be a non-surgical position) and the person interviewing me was basically questioning if I could fulfill the same role. The practice is located in New Jersey and Pennsylvania (so either states scope of practice issues would be relevant) but I'd most likely only be practicing in NJ. I managed (I think) to clumsily communicate the fact that in NJ NPs are independent providers and free of physician oversight and made sure to mention that NPs have prescriptive authority with a collaborating physcian and do not require any onsite supervision. I'm not exactly sure how things work on the PA side of things. One of my preceptors mentioned that PAs can't see Medicare patients on their initial visit to the practice, but I wasn't sure if that was the case everywhere or just specific to that practice. Any suggestions would be great! I have a third interview there Monday and I'd love to have a better answer if the question comes up again.

My hospital tried to pilot something similar. We don't have a unified computer system or honestly even working faxes on every unit. So the solution was that the burden was put on the floor staff. We were given one hour from when the bed was assigned to have the patient in the bed. So that includes calling for report, and then actually going to pick the patient up ourselves. Both ER admits and unit to unit transfers. It. Was. Awful. Half the time the ER wasn't ready to give report, the patient wasn't ready to go, we would arrive in the ER (which happens to be two city blocks away from my unit) to find doctors seeing the patient and putting in new orders (including a patient who was receiving concious sedation at the time to have their shoulder relocated), staff on the receving unit had not packed the patients belongings or prepared them for transfer leaving us to do it. I found it extremely unprofessional to have nursing staff serving as escorts for unmonitored stable med/surg patients, not to mention the fact that I can barely pee and yet I'm supposed to take time away from my patient assignment or lose my limited ancillary staff to go traipsing around our large 500+ bed hospital that encompasses 5 buildings and two city blocks? Supposedly it was very sucessful and decreased our pull times, but we basically just stopped the pilot out of protest for the sheer ridiculousness of it.

Yes! One of my former preceptors was given the option to buy in to an internal medicine practice after being there for about 7 years. Another also started a visiting doctor service in collaboration with a physcian and owned a portion of that practice. And yet another was an NP as well as being a wound care and continence specialist and started her own consulting business after working for another homecare agency. I think it's all about being in the right place, developing the right relationships, and having the savy to identify a need and being willing to take on the business aspect. Of course, you also need scope of practice on your side.

Just to add to the general consensus.... As far as the OP goes...I have no idea! Sure, we have a few patients who buckle. Luckily, PT generally works with our patients post-op afternoon/evening so generally you have a heads up that this has been occuring. If it was really bad, we'd probably use a ceiling lift to the commode or an increased amount of assistance to the commode. Our patients don't generally have femoral blocks (just spinal with bupivicain) but sometimes might have a continuous peripheral femoral/adductor canal/sciatic block or something like an On-Q or Go pump. These are by nature adjustable, so if someone was having huge issues with buckling, it could easily be turned down. We also don't use knee immobilzers on primary TKAs. Revisions sometimes depending on the patient and physcian and if so, then these are worn at all times or very occasionally taken off only for ROM with PT. As far as bed alarms go it is absolutely hospital policy that ALL patients (Ortho or non-Ortho, cleared by PT or not) have a bed alarm set to level 2 from 10pm until 6am. We do have refusal forms that patients can sign, however, we are strongly encouraged to only use this option if absolutely necessary because it really has no legal standing and would not hold up in court to absolve anyone from legal responsibilty if a patient fell. Patients are often frustrated with the bed alarms. A level 2 alarm really shouldn't go off unless your shoulders are off the bed. That being said, I frequently set mine to level 1 if it becomes an issue if someone is a frequent mover etc.. Because they are based on weight, it's helpful to make sure the patient is positioned in the center of the bed and that the bed scale is zeroed. If I have a patient that refuses the alarm, it makes me very nervous because now I automatically assume they are going to try to get up without me. So I don't shut their door unless they demand it and perform frequent checks and if I hear a peep from their room I'm high tailing it in there. So you might want to consider giving the alarm a fair chance before you refuse it. For your safety and your sanity and your sleep.

My school also uses Typhon. We have to submit a calendar at the beginning of the semester and we have a site visit with our clinical faculty. I guess technically they could stop by any day we're there (we're supposed to notify them immeadiately of any changes, illness, etc.) but in reality they don't. My program said we could count all time at our clinical site when patients were scheduled. So you couldn't show up an hour early and look through charts and count it. You can't count your lunch, meetings, drug rep presentations, etc. They also tell us we should be seeing at least one patient an hour. Right now, I'm with a visiting doctor service, so depending on the day and the amount of driving and if someone got unexpectedly admitted to the hospital, I don't always get that but it's fine. Even though we're in the car driving a lot of the day I'm still charting, calling patients and pharmacies and nurses, checking labs, etc. I'm sure your experience will be similar. There's always an issue to be dealt with. Those are every bit of a learning experience and part of patient care and what's we'll do as NPs.

Here's one you might not have thought of. If you're able to work and go to school, your job could very well pay for part of your tuition or at least subsidize your living and healthcare expenses. Obviously every program and employer has different policies, but it's worth checking out. My employer pays 90% of our tuition at the affliated university. I was able to work full time and complete the program over three years. So I have those years of experience, the benefits of full-time income, and my total out of pocket costs are under $10,000. Another aspect to consider is if you'd like to work in a more specialized area, if you could get a job in that area you might be looked at as more experienced. Example: If a neurology practice is looking to hire an NP, who would they hire? A new NP who has never worked in the healthcare field or a new NP who has a year of experience working on a Neuro floor? Most of the jobs I have seen posted for specialities strongly prefer experience. Granted it's not NP experience, but it's something to give you a leg up on the competition. I also think working as an RN first gives you a working knowledge of basic assessment, pharm, and patho, especially if you go in to the experience viewing it as training for your NP role. It's a unique opportunity to see a disease, experience the symptoms, give the meds, and go home and do your research to learn more about it. How can you take advanced classes in these topics if you have no basic skills to build upon?

It completely depends on the rationale for the procedure. If it's just to extract synovial fluid for testing (tapping the joint), then nothing is typically injected. Steroids would be contraindicated if infection was suspected. If it is for pain relief, steroids are typically injected. I've personally only seen betamethasone and kenalog used. Not sure if you could use solumedrol or not. The office I worked at typically did a 50/50 mixture of betamethasone and bupivicain. You could also inject a hylaronic acid type medication (chicken shots) for arthritis. As far as prep, clean the site and then it's a wild care again depending on procedure and joint and provider. Some will use cold spray first to numb, sometimes a numbing agent is injected locally. The surgeon I worked with would hold firm pressure to the area for about 30 seconds and then inject without any sort of numbing first as he said there wasn't enough time for the action potentials to regenerate and create pain that way. I'm not really sure about how it goes for imaging though as this experience was all in a sports medicine practice/inpatient orthopaedics.

I've been a nurse on an Orthopaedic unit for almost 7 years on night shift. I can say how my night goes has aboslutely nothing to do with how many patients I have. I could have three patients at 7pm and be entirely overwhelmed or have 6 and be sitting pretty. There are so many factors that affect safe staffing beyond just a number. Acuity, availabilty of ancillary staff, admisions, discharges, how busy the person I picked my assignment up from was, etc. I can also honestly say I have seen acuity on our unit drastically increase in just the last three years to the point that what might have been a good number then is not now. We almost always work without any ancillary staff and for falls prevention all bed alarms mut be on, all patient's must be accompanied to the bathroom, and staff must remain with them until they are safely back in bed. It's not unrealistic for me to do this 15+ times in a 12 hour shift. We also now must do our own transport, so if I get an admission I have to go get them. Our ER is two full city blocks from my unit. The process, from calling for report to settling the patient in their room, becomes almost an hour process. There's no way to capture or account for this sort of time suck. In addition, our unit has incredibly high turnover. While a day shift nurse might never technically have more than 4 patients, with admission and discharges she might care for more like 7 patients over her shift. Ratios can be used to create unsafe staffing in some circumstances too and you can bet that if a ratio is in place, you are always going to have that many patients no matter what. That being said, ratios at least offer some protection from a completely insane assignment. I know I start to loose track of my patients with the 7th one. I start to forget who is who, when people have meds due, and I just feel stressed and on the defensive. Instead of trying to take good care of my patients, I'm just trying to get everything done and not leave a mess for the person following me. I can also say my manager cares way more about day shift staffing then she does about nights. Perhaps because she's actually there to complain to during the day whereas night shift never sees her. Either way, I don't think there's an easy answer. Ratios are ok but problematic. Acuity would be better but there's no evidence based way to acurately assess acuity to my knowledge. Sure there are tools, but I'm not sure how valid they've been shown to be. It would be nice is administration could be trusted to be vested in safe staffing and listen to nurses when they say it's not. Unfortuneately it's just not the case.

When I interviewed at my current (and first) nursing job, my now manager briefly and individually pulled two different nurses that had recently started off the floor and and allowed us a few minutes to chat in private. This allowed me to ask them a ton of questions about the floor dynamic, the nurse residency program, and the general environment at the hospital. It also showed me the manager knew his staff and was confident that after speaking with them, this would be a place I wanted to work. While that might not be usual, it certainly wouldn't hurt to ask to do something similar. If you didn't want to ask during an interview, you could always ask to come back one day before you accepted an offer.

As a nurse in PA, I've always found this thinking espeically flawed. As a floor nurse, I deal with the ER patients once they came to the floor and the Psych patients before they're stabilized for Psych. While it's true that ER and Psych encounter more overall volume, it doesn't change the fact that some of the patients overlap. It just isn't logically consistent to me.

I had an incident come up recently, but I wanted to see what you all thought. I don't remember all the specifics, but I'll give you the scenario as best I can. I had a patient who had surgery a few days prior. Some kind of Ortho surgery. The patient had been draining from his incision and had been monitored for a few days. I had the patient for night shift. If his drainage was improved in the morning, he was going to be discharged. However, in the unlikely scenario his drainage increased, the plan was to take the patient back to the OR. He was therefore NPO at midnight. At midnight, I removed the food and fluids from the bedside and told the patient he couldn't eat or drink. He basically said he'd tolerate while he was sleeping but there was no way he was agreeing to go the OR and in the morning he was eating. Everything was fine until the residents rounded at 5am. They didn't give him a definitive answer (they were waiting for the attending) and the man began to demand something to drink and food. I told him he was still NPO, but I'd check with the doctors. The residents refused to change the order, even if he was refusing the OR and also refused to come see him and speak with him about it. I tried to keep stalling the patient, but at this point he was becoming quite angry. He was physically not really capable of walking to the ice/water machine. I gave him some ice chips to tide him over. I personally felt like I should give him what he wanted. After all, he can refuse anything he wants to, including being NPO. But my manager said that if I gave him the fluids it was legally questionable. I managed to stave it off till I left at 7am and I'm not really sure what happened after that. Was I right or was my manager right?

I worked two 8's and two 12's for four years before I finally got 12's. I can say hands down I'd rather work 12's. And I think my patients get better care and I'm less stressed. When you work 8 hours you are responsible for the same amount of assessments and charting, you just have four hours less to do all that work. I don't mind giving a few more meds and doing an extra couple of potty trips, etc. And working night shift, no one is happy when you wake them up at 11pm. So I'd much rather get in at 7pm and get them settled and tucked in for the night.

The best thing to do it to check your hospitals policy on blood administration. It doesn't matter what the nurses on your floor say is correct or incorrect, it all comes down to the policy. You are responsible for knowing it and adhereing to it, especially for something like blood administration. I would look it up and see what it says so you know for the future. If it doesn't specify, it should say who wrote the policy or is otherwise responsible for it and you should contact that person and ask them to update it. Always look it up and ask questions is you need to, because the policy should always be the right answer and what you would be held to legally.

Our Duramorph patients always keep their foley till 6am POD#1 (which is part of the reason we don't use it anymore). As far as voiding, our docs tends to be pretty laid back about it. I'd bladder scan at 6-8 hours unless the patient was complaining of discomfort. We don't cath unless the volume is over 500 or a ridiculous amount of time has passed. The answer is usually give them more time and get them up and walking. And if they're peeing at all, even as little as 25-50mL, they won't cath them unless the volume get up around 700 or 800 or they're uncomfortable. Everything is about the minimum intervention possible.

We actually had a patient who faked being a para just to get a helocopter ride. He was miraculosly cured when we told him his family couldn't wheel him to the lounge in a geri chair, but that instead he needed the special tilt back wheelchair with the seatbelt due to his paralysis. He got right up and walked. I work on a primarily Ortho floor so our favorite line is that things like wiping are part of therapy and that everyone has to at least try. Sometimes the larger spine patients genuinely do have a hard time reaching, in which case a prompt call to OT is made to get some tongs. It's important to start practicing early! I never ask who does it at home anymore because one time I had a patient answer that his wife had been wiping him for the last two years. I was completely astounded.

Our situation is a little different as our Ortho unit is actually comprised of 4 individual units all managed/staffed by the same people. Two of our units open and close with patient flow. One 18 bed unit is typically open Mon-Fri (sometimes Saturday if census is high) and the other Wed-Sat (sometimes closes Friday if census is low). One nurse comes in between 7 and 7:30 to open the unit, making sure that chart packs are set-up, kits are in the rooms, equipment is where it needs to be, etc. Ideally there is an aide or clerk there as well to assist. That nurse takes the first few early post-ops. Another nurse comes in at 9am to take post-ops. Then two at 11am to take the rest. The opening nurse leaves at 3:30 and if the unit were full a 3-11 person would come in but its usually not. Our staffing is a combination of 8 hour shifts, 12 hour shifts, and odd part-timer shifts but because our unit is big (70 beds in total) we can easily fill in the holes or bump people to accomodate for admissions/discharges. I'm not quite sure how you'd do it if it was just a single unit. On days the unit closes it's usually 1-2 nurses and an aide after 3pm depending on how many patients are being moved off and then they spend the reminder of their shift locking rooms and putting equipment away. We have to lock our rooms because we've found homeless people sleeping in them before. Oh the joys of the city. We also have cameras on our pyxis because it has a habit of getting broken in to when the unit is closed. I know that's not the most helpful but it's something.

We are a large, level one trauma, inter-city university hospital (I think like 800 beds??). Our hospital has a first call policy, meaning you must take report on the first call. There is no grace period given for change of shift. I know this is done for patient flow, but as a nurse it's very frustrating. It seems as if the report is frequently "held" until the change of shift resulting in most of our patients coming just before or just after nurses are coming and going. It's really not safe for patients from our perspective. We have had 5 post-op patients rolling up to the floor within 15 minutes of each other. Regardless, we make it work although we frequently beg for even a 10 minutes before and ten minutes after window.

On our unmonitored unit, we generally don't give IV pain meds (never push and most patients come back from the OR with a PCA which is then D/Ced). Once a patient is converted to PO meds, any IV meds ordered would be considered for breakthrough only or special circumstances (heavy PT sessions, special testing, etc.). In this case, I would have given the patient both the dilaudid and percocet as you did, but I would not have continued to give the patient the IV dilaudid. Percs Q4h first, and then an additional dose of dilaudid. If the percs alone weren't covering, then the docs should consider adding additional PO meds. Of course, this rule of thumb is assuming a patient is going to be headed home and needs to be on exclusively PO meds. Now clearly this patient is a bit of an exception as he was returning to the OR. The important thing is that you spoke with the doctor, assessed your patient, and managed his pain.

It's important to know your hospitals policies and your doctors protocols. Do foleys and PCAs have to be D/Ced at a certain time? How often do you need vitals and I/O's? What sort of documentation do you need to do? For a lot of new grads the biggest time waster is going back and checking to make sure everything they were supposed to do it documented. Include a list of checkboxes so that once something is done and documented, you can cross it off and know it's done and not have to spend time going back to make sure you did things. It also helps remind you what you need to do before you walk into a patients room. A lot of the nurses I work with use stickers or index cards on their badges to remind themselves about our protocols.

Our docs feel that lovenox causes increased serous drainage from the wound and will NEVER (almost) use it. We use coumadin exclusively per a dosing protocol based on INR with the goal being 1.5-2.0. If the INR goes over 2.0, coumadin is held. A few docs use aspirin for THAs. In the event of a PE, patients are put on heparin until they are therapeutic and then take coumadin. As someone with experience, I would say I would rather take coumadin, even with the risk of side effects and monitoring over the lovenox. The lovenox injections were painful and annoying, and even with insurance were $15 for a 5 day supply versus coumadin which costs me $5 for a months supply. Our patients INR is monitored at home in conjunction with their visiting nurse follow-up care and home PT.

I started Ortho fresh out of nursing school a year and a half ago and I love it. As a new nurse, it was nice not to be dealing with life and death issues on a regular basis. As far as experience, what you learn is pretty specialized. I can say I've lost a lot of skills from nursing school. I've only seen some things a handful of times (trachs, NG tubes, PEG tubes, colostomies, etc.) You do get great experience in treating pain. Ortho patients can be great (you can have a normal conversation with them) but they can also be VERY demanding (sometimes they forget they're in the hospital and not a health spa). You do still see some sad stories (people with chronic infections, dislocations, etc.) and rarely, people loose a limb. But in the last two years on my very busy ortho floor, we've have one code. It can be a lot of lifting, but that should encourage you to learn to do it the right way. I think the heaviness also brings people together to work as a team. No one can take care of all their patients by themselves, so everyone has to pitch in for everyone. As far as the docs, I work at a teaching hospital. We have the same group of 7 residents for two years responding to our pages. We actually get to know them and they get to know us. As in, they know our names. And call us by them. During the day, we have nurse practitioners who handle our pages (and all of them started as staff nurses on our unit). Of course that kind of thing is dependent on where you work. There are some drawbacks and I don't think I'll stay forever, but over all I'm happy I started on Ortho.

Our standard joint care plan covers 7 areas. I'll just list you out what it looks like Pain Management - Pt will verbalize tolerable level or pain on oral pain meds and be discharged on these medications to home/rehab Mobility - Pt will demonstrate proper ambulation safely w/ assistive device as needed prior to discharge to home/rehab. Tissue Perfusion - Pt will demonstrate adequate tissue perfusions as per CMN checks upon discharge to home/rehab. Infection Control - Pt will verbalize signs and symptoms of infection and 2 ways to prevent infection prior to discharge. Management of Pt Safety - Pt will be free of falls during hospitalization. Dischange Planning - Pt will verbalize understanding of follow-up plan upon discharge to home/rehab. Potential Alteration Anxiety r/t Hospitalization - The pt will verbalize 2 ways to reduce feeling of anxiety during hospitalization. There is then blank space to enter any futher specific goals for the pt related to nutrition or another condition/issue they may be having. That's the cover page. Inside there is a page to prioritize the goals daily, a place for all members of the team (case management, PT, OT, dietary, pastoral care, etc.) to initial when they see the pt and enter their name and contact info. The next page is to assess barriers to learning and motivation to learn and the pt's anticipated learning needs (self-care activities, safe and effective use of medical equipment, pain risks assessments and treatment, safe and effective use of medication, potential food-drug interaction, and determining need for further treatment) and a place to document any teaching materials used. The last page is to document teaching about the surgery, any meds, pain management, counseling, treatments, procedures and the pt's response. This is basically our hospitals standard, blank care plan filled out for our ortho pts. It's focused toward hip/knee, but we do use it for other surgeries. We have a seperate POC for spines. And if it helps, we have our disease specific cert in hip/knee.