EastCoast

Hi. Jumping in. As a previous bedside nurse on the ICU i found rounds helpful. Learning. Building relationships. Establishing credibility. I also felt as a Nurse Manager that your patient's call light was everyone's call light. Rounds i think are important. THoughtful patient focused conversation is never a waste of time but handholding and standing there like a moron seem a waste of everyone's time. As an NP who rounds daily in the hospital I will almost always ask the nurse if there are issues. I don't expect a nurse to round with me. I can take care of myself. If i write a ton of orders I give the nurse a copy as i find it annoying 3 hours later when the nurse doesn't know about the lasix i ordered. It seems to work on both ends and the patient seems to benefit. I read the notes on the computer that the nurses write. Most of the nurses I encounter I find are pretty good, still every once and a while at 3 am i get a call and can't for the life of me figure out how that nurse got through clinical. I recently saw a temperature is the computer as 31.2 celcius. I asked the nurse (student) if this alarmed her. She said no. She didn't understand taking the temp after giving the patients his meds and H20 would affect the temperature. Last. . .you can't teach some of these old doc's new tricks.

Hi. I actually work as an NP in HTN and nephrology. This is what I tell my HTN people who don't think they need an evaluation. Kidney failure is a direct consequence of poorly (note not even uncontrolled) B/P. Dialysis is a tragic consequence for denial and stupidity. Strokes are devastating. If your friend doesn't think he needs attention ask him to visualize himself getting fed by you once he's had one. Fatigue is a SYMPTOM of high B/P. I am not sure why folks aren't told this but it is. Also, isolated B/P reading should never be recognized at HTN. A journal is so useful and resting for a few minutes before taking it is optimal. I am a fan of the tough love approach and since you've banged your head against the wall and your friend seems to be in denial. Last. . .i woud suggest that once he goes on a medication his lab work is followed closely. If he is put on an ACE or an ARB and his kidney function changes it may be a sign of significant renovasuclar HTN which needs close follow up. GOod luck. Have him find a good doc/NP who you consider knowledgable. Dying young is devastating and as we all know. . .it does happen.

In response to the last post...I understand your desire to accelerate your career and I wish you good luck. However, I think that a NP is better served getting their nursing degree.......working as an RN and once they have that down getting their NP. I think while it may be perceived as bitterness, it is really advice from those who are really nurses first. It's a stick situation overall and it shouldn't discourage you from nursing. It should really help you to understand that nursing is a practice first. It's not just a career stop along the way. For me I look at the accelerated programs as a way for the university's to make money and sell the dream that you will be able to truly practice as an NP and make thoughtful wise decisions. I'm not sure that is always the case. Good luck to you no matter what path you chose.

Appreciate clarification of Program terminology but on the same note.. why not DNP instead of DrNP? or why not DrNS instead of DNS. IMO the small 'r' after the "D" make a difference in peoples perception. For instance, why isn't there heated debate about DNS? No on cares when someone says they have a doctorate in nursing science. But it becomes a turf issue when it's a DrNP.

I'm looking at Columbia's outline and it doesn't mention too much about changing the overall plan for administration, scholary work or policy making. In fact it seems to focus on the primary care gap that needs to be filled. Currently, NP's (the regular kind) seem to be filling this. Columbia presents that the new DrNP will be a better option and make it more attractive for nurses to enter the field. My other quirky curiosity is: why does the Doctor of Nursing Science have DNS but the Doctor of Nurse Practitioner have DrNP???? Why not DrNS?? Can no one else see why the Physician's might find this irritating?

Hmmm, Well, it's not the money, it's not the time, I think it comes down to my belief that we are not a cohesive enough group from state to state and that it is created in the realm of 'academia' rather than clinical. I also know that there is no guarantee that just because you are a DNP you will be able to admit to a hospital or gain any further privledge in a medical environment. I consider myself well regarded in my hospital. I'm not sure however the medical staff would say okay to me admitting my PCP patients under my own name. Is that a thorn in my side? Certainly, but I'm not willing to grandstand about it as I also feel that a previous NP with marginal hospital experience put several of us in a bad position. For instance, now when reapplying for privledges the President of the medical staff has to 'approve' our competency. I work side by side with him however, i believe it was set up to get rid of those who he doesn't feel are up to par or perhaps causing him aggravation. While this would likely never happen to a doctor I can bet it would still happen to a DrNP. It is still a world that many doc's look at NP's as trying to steal their money. As long as that bias exists we will have difficulty. If we continue to have inconsistent standards for entry, varying degree requirements we will have difficulty. Those who choose to enter DrNP I am not against. Good for them. I just think it is a white elephant that does not make you a better NP in the end. I am not sure the intents of those who make the money are pure. It doesn't make you a doctor. It gives you an additional degree. I think that is what pisses doc's off is the attitude of the Dr.NP component. I mean why not just have PhD with a clincal component. I think truly that some people will get off with the being called doctor thing and really won't have to correct the patient. It's misleading.

I agree with this last paragraph except for your very first sentence. You may be mistaken for a doctor because you haven't introduced yourself prior to your encounter. So if you get a DrNP will you clarify the difference or feel 'well...i am after all a doctor'. Also....in my opinion professionalism does not equal 'doctor'. Ask most nurses the number of professional docs they encounter in a day and it will probably only take 1 hand. Many docs mannerism that appear professional can also be seen as quite standoffish. My patients will often tell me they like NP's better than docs because of the of being able to feel comfortable and that we take more time to really listen to the docs. If one of my patients told me I was like a doctor because of my manner I'd check to see if they were talking to the person behind me. A compliment is them thinking you may be a doctor should be because you have sound clincial judgement and good outcomes. As an aside, If I had to do it again I just would have gone to med school. I'm the first to say that and I don't stand on the premise of I couldn't ever not be a nurse. Nursing was good to me but overall I wish I'd worked as a nurse for 5 years of so and then went on to med school. It is for me just a matter of having bad timing. I'm a thumbs down for the DrNP. I think it's stupid and just another way to get money and make the AMA hate us even more.

Bridge program: RN---licencse---MSN---boards--NP only clinical is academic. No non acadmeic nursing required prior to obtaining np. Get done with school...pooof... you're an NP.

Markdanurse, I think we share the exact same opinion but I think you read my post different than i intended.. I was actually agreeing with your post but asking the age old question of why people like to say 'that's more clinical hours than a PA needs'. It usually is used to justify a bridge program with little clinical background.

Why do people always compare PA school clincal hours to NP clincal hours. A good NP program that requires nurses to be nurses first will likely require less clincal because the person brings the clincal with them. It doesn't mean it's a bad program. PA programs are different. They are medical model based and I think you would be better prepared in gross A/P and surgery than NP programs.

I think that Siri you sum it up logically via a process of learning and working and applying your previous knowledge to make decisions in an independent manner. But people continue to miss this holy point. Those who have no background and have not gone through the process will never understand the point and the utility of that type of learning. Ultimately it will be the patient who pays the price for textbook care and our profession as a whole will continue to be viewed as inconsistent and willing to give anyone a degree. I say this often..."NP's work 3x as hard as docs to get things right because when an NP screws up there will be someone there to say "see this happened because they're not a doctor". To me I don't care about how people pass their boards either. It is not that hard to pass boards if you study hard enough. I do not believe that a milllion clinic hours make up for basic experience. So what... you have 1200 clinical hours and you 'aren't allowed to work'. That's a pretty sweet ride. My last student was with me 2 days a week and wrote some paper on some subject that was interesting but that's as far as it went. I would have much rather she spent the time figuring out how to assess a patient within a reasonable time frame and still get a decent note written. And this was an experienced nurse who really was outstanding at the bedside. Funny, how she actually thought being an NP was a 'big deal' and understood what her nursing brought to the picture. It was here nursing that she brought forward to each an every patient. I was much more tolerant for her struggle to do it right and well versus just getting the job done. However, the proof will be in the pudding when you don't have the text or your preceptor at hand to bail you out. When you do not have the memory of a similar situation as a nurse and how the team as a whole handled the patient. When you are asked by a famliy to explain the whole nuts and bolts of a case and you don't have a Bates to rely on. I still have to ask...why are you going into nursing again?

Well said Mardanurse. Again the posts from people who want to just go to NP school for the glory and authority (IMO) have little knowledge of the guts of nursing. A chimpanzee can draw an ABG and perform tasks. In fact many of the things that are procedure driven are now not done by the RN. However, it will be a nurse who can figure before the ABG is back that the patient is alkalotic based upon how they look. I will say it for the 10th time. Please, NP's without experience....stick to your minute clinics where a rapid strep willl make your diagnosis for you as opposed to clinical exam. Stay away from hospitals. You'll end up killing someone.

Patrick, I think that is what so many of us feel. However, those who have never really been nurses in the same way that we have, can not understand this. Very recently my famiy member called (who is a nurse) and asked as a favor that I precept someone who was doing a bridge program "rn to Pedi NP" that she had met while she was doing her clincal on the same unit as my family member. I flatly refused. I am not going to tarnish my reputation by allowing someone who has not established credibilty in the clinical arena to care for my patients just because by the time I would do this she would have her 'RN'. Honestly, I 'd rather take a strong LPN who has worked at the bedside and have them get a masters degree than take an RN with minimal training. This is the reason that the AMA continues to not support us. We have too many options and the criteria for getting your degree seems to dwindle daily. And as far as one of the previous posts that says 'as a smart new grad one will know when they are in over their head'...I tend to disagree in the realm of the NP setting. A smart new grad who is working as an NP with no strong background has no basis to differentiate exept when something goes terribly wrong.

Let me sum up my thoughts exactly: As an NP you will be responsible for people's lives. It's not that easy. It's not about how motiviated one is in their desire to accept responsibilty. But oh boy, it's a big responsiblity that will sometimes wake you up at night and sometimes when you are driving in your car you will realize how important your job really is. In dealing with families, crisises, other providers, n and sick patients, your previous experience as a nurse will make a big difference. You will have seen different situations, and applied your knowledge and theory to the situation at hand. But...in this discussion.... if you never have worked as a nurse you will never understand so it is a futile argument.

Clearly, you have yet to work as an NP and therefore you do not understand what I mean when you have to sort through things over the telephone in the middle of the nite and you have only the RN to help you. TO take it as a 'hostile' post is clearly defensive. It's stating an opinion based on 15 years as a critical care nurse followed by another six as an NP in a hospital. When you are an NP working in an acute care setting then you have a basis for opinion. To believe that my post actually suggested think a provider would call someone in and say 'i think you have cancer because I have a hunch' is ridiculous. If that is what you read in the post then you should reread it. It's talking about the middle of the nite call when you only have the RN on the phone and you are covering a doctor and have no idea who this patient is. Secondly, As far as the med schools and PA schools go...it's apples and oranges compared to NP schools. A NP student can not compare to a med student. Period. THeir clinical hours are entirely different and more intense for the med student. IT is the reason when a doctor becomes a doctor he doesnt' have anyone to 'fall back on'. In many states it is the requirement that an NP have a collaborating physician. That is not to say that many NP's are not as good as some docs out there. However, training is an entirely different subject. If you 'fast track' how many years of school is that and what are your clinical hours versus the medical student. Please, do not suggest that you're training in a bridge program is equivilant. THe reason it's called a NP versus a P is the Nurse part. It was the original intent of the position and the no experience required is taking away the very thing that made NP's different.

Zenman, I think our thoughts are the same i just communicated mine differently. If you've been a nurse long enough you know what i mean. Not the 'smart' one who has thousands of letters after her/his name and has climbed the almightly clincal ladder with a beautiful portfolio, but has run off to so many meetings that the others have to cover. I mean the nurse who is and good both clincally and academically. Intuition, or even having been around long enough to know a sick patient versus a not so sick patient. I think intuition is very powerful but I also think that seeing patients day after day and learning 'nursing' at the bedside is key to being a successful np. I would like to think that I was also smart and good. See, IMO you can be smart but not good. It's difficult to pull off being good and not smart too.

I agree. If a nurse with crappy experience calls me during the nite and can't give me a 'gut' feeling of whether the patient looks good / bad/ or inbetween then in short my patient is screwed. I don't want a 'smart' nurse on the end of the phone. I want a 'good' nurse. There's a difference that only a nurse would understand. All of you who want to skip the nursing part in my opinion will make for marginal NP's. Good luck... you go against the very grain that many NP's are spending their time and energy fighting for in legislation. I suspect if you are taking the short cut to get your NP you will likely take the short cut when you deliver care. Holy cow. Next you'll be asking to do surgery cause there's a bridge program somewhere. If a doctor moves here from another country many times he/she is forced to repeat an internship. I believe this is often unnecessary. In comparission we allow individuals with no experience are allowed to sit for NP boards. This is a crazy system.

hi again, I also meant to say that the dialysis nurses will likelyl know this patient better than the fmaily does and will be a very good resource for you. There is usually a social worker who should get involved in this as well. I feel bad for your crappy weekend. The company has clearly taken advantage of your good nature.

RE:What Zenman said. I completely agree and somehow missed that in the previous post. I think you will struggle to be a 'good' NP as you are limited in your experience. Dealing with difficult patients,tough families, learning the ropes, having a bad shift...those are the things that build your strengths. I would venture that most NP's will agree and those who don't are those who have followed this same path. In your career I suspect you will be limited in what your abilities will encompass. For instance, even though I am a huge midlevel supporter I would not want an NP who had no experience except classroom and clinical. Good GRE, research, community participation...that's all wrapping. SHow me someone who can run circles at the bedside and I'll show you a strong NP. I believe the 'fast tracking' undermines the NP profession and schools desire to make money off of these people does as well.

I work all but 4 days a month. So that's the bad part. My background as a bedside nurse was critical care, then i went on to school and did administration as director of critical care and emergency room. Currently, I see office patients who are my pcp's 2 days a week. Every day except for 4 designated work days I see my hospital patients (consults/ pcp). I work in nephrology and htn and we have a bit of a PCP following. I take call 8 days a month. That involves doing the hospitals consults and admitting any of our patients to the hospital and answering the ridiculous callls that should have been placed during the day. FOr some reason people only need anitbx. or pain med at 5:02pm. I get paged during nite to the er. that's not so fun and as well the floors where all our patients are located. I work with 3 docs. 2 I like. The other is a jackass and thinks he's God. I decided he likely carries some sort of psych diagnosis that is related to his high regard for himself. I don't know anything about psych so this is just my opinion. I work my butt off. My salary is good. SOme days I work harder than others, that's the way it goes. I feel i have really wonderful credibility but there are always the few that you just don't know what they think of you. For 2 years prior to this job i worked as 'house officer' and covered the hospital as would a senior resident or house doc would. I learned amazing things inclulding central lines, running codes, intubation, and critical thinking. My nursing background gave me a very good basis and I think this made all the difference. It's funny, everytime I think of doing something else I realize that i'm not qualified for anything else. good luck no matter where your journey takes you.

I would likely say that if it is an emergency repair then perfusion to the kidney has been compromised by shock. Even short intervals of hypotension can lead to renal ischemia. Also, if they clamped the aorta during surgery for any length of time then blood flow again to the renal beds was impaired. Also, and i always go back to this when i'm looking at someone with 'renal failure'...their state prior to the procedure is very important. Did they get dye for a ct scan? If so there's a big reason especially with diabetes. what is the baseline. Remember creatinine is a product of muscle mass. The little old lady with a creatinine of 1.0 already has renal failure she just doesn't have the muscle to generate enough creatinine to reveal itself. Renal failure is more concerning when the creat. goes from 0.8 or so to 1.2 or thereabout rather than those who started with a creat of 1.9 and and it goes to 2.3. the degree of renal failure is different in those two cases. As a nurse your 5th VS should be urinary output. Do not wait till the end of the shift to see if your patient urinated. It's a huge thing and unfortunately the I and O is often delegated to a CNA who may not report that only 100 cc was made in an 8 hour period.' Sorry for the rant...i spent hours on ARF and usually it is completely avoidable.

1. If the patient goes to dialysis the center will have a current list of his meds. It's likely he goes either mon/wed/fri or tues/thurs/sat. Find out first thing tomorrow what center he goes to and where and then call them and make sure they know he is very far from his home as they need to get in touch with another sister agency to make dialysis arrangements at least for the short term. 2. Call the answering service for the doctor again. Who gives a crap if you're a pain in the butt. All answering services are required to keep a record so a second followup to see if they delivered the message won't hurt. 3. The sister herself should be calling the brother's doctor. Sooner or later a family has to also be involved when it is a circumstance like this. 4. It is unlikely there is any litigation involved. Don't panic yourself about this. You advised the sister to go to the hospital. SHe said her brother seemed okay. DOcument that. Therefore, when her brother goes into heart failure you covered your butt. 5. Ask yourself if this is really the job you saw yourself doing when you were in nursing school. I can't think of a salary high enough that would have been worth your aggravation and likely overwhelming sense of responsibility for things beyond your control that you have experienced this weekend. good luck

http://www.emedicine.com/med/topic2956.htm I'm sure you will get a dozen responses, however, this does a nice job of giving the theory and is quite straightforward. I learned swans a long time ago and i still carry around in my bag an article written quite similar to this. GOod luck.

THough the patient has gotten by for 2 days with this ABG I think that the pO2 of 48 is concerning. If this was my patient i'd do the following... repeat the ABG. It's alarming to see a pO 2 of 48 without significant change in PH even with compensation unless he has COPD. Also, what is the Percent sat?? if it is less than 85 percent I'd say that meets criteria for intubation. While BIpap/Cpap is an option his Pco is not significantly high enough for him to blow off the CO2 nor will it be beneficial if he needs pulmonary toileting and needs to clear secretions. If he has gone 2 days with a PO2 of 48 and a low o2 sat i'd worry about anoxic brain injury. What we do not have is whether this man has COPD or restrictive lung disease as a baseline. In this case I'd not be alarmed by the gas but would consider bipap. In this case trying to improve his o2 conventionally may be dangerous as he may be able to tolerate the po/co level (it's near 50 /50) with a near normal ph and where by giving him O2 would cause further demise as mentioned above by losing his respiratory drive. In short though, i'd likely intubate him as it sounds like he needs to rest on a vent.

Hi, Fairly new to this board but I must reply to the response that attending to details aside from the initial presention (the person with a lac and low BMI and having discussion about that circumstance) will not get reimbursed from Medicare. In my role I bill for what I do. If i have a conversation about preventive health or about circumstances that may contribute to the complaint it is documented in my note. I use a modifier and bill appropriately as an extended visit. I'm sure that sometimes I spend more time that I will actually get reimbursed for but that's the breaks. I'm not going to skimp because of medicare, I'd rather take 5 extra minutes and detail the note in case it does get audited and make sure that i've taken care of the patient fully.