KatieMI

The Board exam for ACNPs is not "FNP". It is quite different exam, ACAGNP. Content of both exams has not much in common (I passed both). One doesn't have to "obtain experience" before entering either MSN or DNP pathway. There are plenty of programs, including big names, admitting students directly from undergrade and even direct BSN to DNP programs. Some of them (for example, Georgetown University) cost more and take longer than an average medical school. Post-graduate certificate programs are generally one year long. Most of them (except famous "mills" like Marywille) require experience working in acute care as an NP, although what is considered "acute care" is totally up to each program. Half of my class (post-graduate certificate program) were working in walk-in clinics, urgent care and such - and many of them happily returned there after graduation. Another half worked in hospital setting in all types of specialities from ICU to ER to hospital medicine + acute subspecialities. ACAGNPs and FNPs do exactly the same job for exactly the same money in many settings (aforementioned urgent care, walk-ins, LTC/SNF/acute rehab, combo "office+rounds" in specialties, etc.), and the question "can an FNP work in acute care" is more about every facility's credentialing policies than anything else. More facilities start to require ACAGNP certification as a requirement for credentialing - as well as either previous experience or "residency" (which can be anywhere from good to ugly as currently there are no standards or regulations for these activities). Salary of ACNPs is generally lower than one of ER NPs in the same area because almost all ER NPs are trained to do procedures while many ACNPs do not do them at all or do only those which are required by their specialty (although crazy wide local varietes are possible). CCNE can mandate whatever they want and set whatever deadlines they like. No one except CCNE (schools, prospective ACNP students, ANCC, AACN and employers) is particularly interested in forcing additional +/-2 years of classes which would add little to clinical knowledge but a lot of $$$$$ onto prospective students and potentially depleting job market which is already quite hot and with no much doubts will became even hotter in coming years. The talks of getting LPNs out of acute care and making BSN entry degree, with supporti ng evidence, are going on for like over 30 years now while LPNs are actively recruited to work in hospitals. I bet it will be the same story with "mandatory" DNP for acute care.

It is most probably about $$$$, not about knowledge or absence of it. Consultant gets paid for his job, in exchange "their" patients are admitted under hospitalist primary so that the said hospitalist gets his check as well. Hospitalist service by itself cannot produce quite as much money as consultants because all insurances "value" them less, but it usually more than makes up the difference by volume. In addition, if every specialist has to write up all H&Ps, daily notes and do all hospitalists' scutwork, speciality services, which are expensive to keep and support, would be blown up in numbers while bringing the same revenue. It wouldn't be enough to keep just two GI docs (one rounder, one doing procedures) for 400+ bed hospital which takes, say, on average 12 "pure" GI cases daily with same number of discharges and at any moment fills about 8-9% (32- 35) of beds with this type of patients. Only existence of cheap labor force "support" such as residents and APPs makes it possible for just daily functioning with straight specialty responsibilities, with no H&Ps, discharges and all that jazz. Not a rocket science, just all-mighty green paper game.

I have hospitalist job 3/12, but it is a rare pick where I am. I agreed for this specifically to allow myself to go back to school (FNP, doing AGACNP for coming interstate moving' sake). The previous job was 4/10 irregular schedule and it was absolutely awful, no quality of life and work at all. It is not a job for a novice unless either 1) the place has an excellent orientation for good half of the year, or 2) one did a full fellowship. You will be expected to do 90+% physician's job. It might be easier if the place is consultant-heavy (but if it is the case, you might find yourself working for years and not actually treating anything beyond calling consults). In my case, I am considered a full partner and not expected to call supervising physician, who in any case not physically available "too frequently" (read: as rarely as possible). I enjoy being independent and I am paid pretty well for an NP. But it did not come lightly.

Small (25 beds) critical access hospital. 100% autonomy, on my days on I am the only one provider on floor. Support, if I need it, from ER doc and from "main" hospital over the phone. Enjoying it immensely.

There is one in Philadelphia at La Salle University and International Nursing museum in Scottsdale, Arizona. I'd heard there is a private one in Glendale, Arizona as well. Here is some more: https://www.aahn.org/travel-to-nursing-history-site Not to mention several more excellent nursing museums in Europe, including the first and probably the best one, initially dedicated to the story of Florence Nightingale but offering a whole lot more to see and explore. Once travel restrictions are lifted, it is in London directly on the campus of St. Thomas hospital in the very heart of the city. Another one I love is in Brudges and dedicated to work of Beguines sisters who still run local mental health rehab center. In London I remember, among many other things, the list with roughly 1890th nursing school coursework which included, among other subjects, cooking which paid specifically painstaking attention to making "medicinal broth" which required breaking bones in beef in pieces with a "club" (wooden mallet of a kind, or so I guess). I bought a card with this recipe and tried it when I got back home. It really makes good "bone" type stock, maybe not so much "medicinal" but just very tasty ?

In my time, I loaded them on a cart, brought in the corridor near hospital library and quietly left there with a sticky note "free books for everyone, BSN/MSN from X university just done". Did not bother to tell anyone. No idea what anyone was thinking when both carts were found but saw some people reading them during quiet times in a week or two ?

Not from the USA, but good analysis: https://www.alliedacademies.org/articles/analysis-of-pressure-relieving-mechanisms-for-the-prevention-of-decubitus-ulcers.html Apparently, the waterbeds are mass marketed with the goal of pressure wounds treatment/prevention from 1970th, despite of paucity in studies. I'd seen chronically bedridden patients using waterbeds or even Clinitrons at home when I was in LTACH. By themselves, the beds did not solve the problem of those appearing-out-of-thin -air bedsores from sheets' wrinkles. Those patients in general had much less bedsores than it would be expected in their situation (usually permanent vegetative condition on vents) but they received the most meticulous care 24/7 and were turned more frequently than prescribed Q2h. In fact, most of them had almost pristine skin as long as they were well cared for and their nutrition was as close to ideal as it was possible. I really think that it was not so much for the bed as for level of care to keep them alive and (mostly) well for years and even decades. Once something changed (usually, a person who was supervising the care with a good degree of clinically significant OCD got sick or was otherwise removed for some reason) the patient's condition deteriorated in days despite of being in the very same bed. Although, when once we had a working Clinitron torn, it was quite literal description of s*** hitting the fan. I am afraid to think what torn waterbed would look like.

A nurse (or APP, or physician, for this matter) can take whatever drugs necessary to support her/his health, including opioids, benzos, psychotropics and so forth, as long as there is a current provider prescription and the drug doesn't limit the full participation in job functions. Not employing a person basing only on the fact that this person takes a medically needed substance (which will be easy to figure out as the job offer rescinded right after preemployment physical) is against multiple laws intended to protect persons with diseases and disabilities. It is so in all 50 states and territories too. There were multiple incidents when phtsicians were denied employment under similar circumstances. Docs are, as a majority, way more legally literate than nurses and the legal actions taken by them were mostly won. The only one notable exclusion so far is medical marijuana but even this starts to change.

You can work in Internal Medicine (including Gastro, Cardio, Onco, Nephro and everything else) clinic with FNP without any problems or additional certifications anywhere in the country. You can also do specialty rounds in hospitals (if your job description and contract require this) in many (but not all) places and states. There are specialty certifications available through corresponding specialty organizations but they all require regular (and at times quite high) fees, matter not that much overall and completely voluntary. Only one notable thing you can get through these organizations is specialty CME. Before COVID19, there were also networking options through conferences but now it is all placed on hold indefinitely. You do not need specialty nursing experience for this, but try to get friendly with specialty consultants if you now work in a place where they appear.

One job which is quite similar but better in so many senses is doing "face-to-face" for hospices. It is also about visiting homes whuch can be, er... different, but at least you perform real physical and use VERY real clinical knowledge. And most people realize how much you are needed and behave accordingly. You'll need DEA # as you are going to prescribe a heck of controls but you are paid per visit and get real experience. Plus that feeling of helping people at some of the most difficult momenrs of their lives.

Worse yet, I am usually the only one provider who takes time to sit and explain those basics. I do not know how schools nowadays let out nurses who literally do not know ABCDs of pathology and pharma and how these nurses successfully pass NCLEX in droves and get employed without having the slightest idea of what they are playing with. Oh, bother....

Policies vary but computer self-taught modules are hardly ever (if ever at all) are paid exactly for the reason you noted: there are some people who can do it quickly and there are some who can't. And there is no ways to control or check if one really does the module or just keeps monitor at hands' length and moving cursor from time to time while doing whatever else. I was always paid for in-person activities and never for virtual ones, although some of them (coding) could be converted into CE. In the future, you might have paid "CE hours", look for them in your contract, and possibly (not guaranteed) can incorporate some of that education into them. P.S. this is not your "second job", it is your first job as APRN. You are considered all new and fresh and starting from square "0", doesn't matter how many years you were RN before.

One thing for you to remember iron-hard: - there is no such thing as "good" and "bad" physiologic process. Blood pressure, coagulation, cholesterol, etc., CANNOT be "good" or "bad", just like rain or the Sun. They are here, and we are managing them when and if needed. If you find yourself not knowing and understanding questions like this, it means your level of knowledge is critically deficient. I hope that what I wrote above helps in some way, but it won't substitute for your patho and pharma books and lectures, which you must dust off and re-read till you understand every single word. I purposefully did not go into INR question. Knowing and understanding all the above, it won't be too difficult for you to figure out what INR is and how it changes. To show your work: if patient experiences liver failure, where INR will go, and why? Counting for your other posts as well, I wonder what kind of school "never taught you" about this basic info stuffed tightly into NCLEX. Accounting for how frequently a nurse should use knowledge about coagulation and how many patients are taking meds affecting coagulation, it looks like you might want your money back.

Continuing: Without much ado about biochemistry (most interesting part for me, but it is another giant talk): Both clotting pathways work similarly. Each is a row of chemical reactions when one component (they are all proteins which present in plasma in non-activated condition and they all got names which always start from F, for "factor", and continue as a number in Roman numericals, like FII, FX, FXII) activates the next one, which activates the next one, and so forth till FX, or "Stewart-Power factor", becomes active. FX is the central key component which ties extrinsic and intrinsic pathways into one and, with help of other "F"s, makes a plasma chemical named "protrombin", his other name "FII", into its active form "thrombin". Trombin activates another plasma chemical named "fibrinogen" into its active form "fibrin". Fibrin looks like thin and very sticky threads. These fibrin threads stick to exposed tissue, vessel wall and blood cells and form thrombus which cloths the vessel. Now, several "F" proteins are made in liver. Several of these liver-made proteins, namely FII(protrombin), FIX (which only works in intrinsic part) and that all- important FX guy need vitamin K to be made. Coumadin blocks action of vitamin K, therefore if patient takes coumadin, factors FII, FIX and FX are not made and blood won't make cloths. Just in case so that all this big system won't start running at a random place and time, organism has at least one chemical blocking each step and every chemical in coagulation cascade. These chemicals do not work like an avalanche and instead stop every cascade step as they go. At norm, coagulation and anticoagulation systems balance each other. If you cut your finger, local activation of coagulation cascade happens and only the wounded vessels are quickly clotted. If some platelets stick to the aterosclerotic plaque in your aorta (all humans have them after early childhood, so do not worry), local anticoagulation kicks in and cloth won't form. But, there are conditions which move balance toward coagulation. These are: - slow, static blood flow (for whatever reason- immobility, dehydration, low blood pressure) - inflammation (caused by whatever) - pregnancy - trauma - too much platelets - various debris swimming in blood (think about metastatic cells, bacteria or microscopic pieces of broken bone) - and quite a few others. Some people genetically have proteins in their plasma which activate coagulation (if you ever hear about "factor Leiden", that's one of the most common of them, but there are over a hundred of them known for now) In these cases, coagulation becomes our enemy, because blood starts to get clotted rather randomly and in dangerous places. Since leg veins are wide and "soft", blood flow is normally slower there and cloths happen more frequently. They flow into vena cava, then in right heart, then into pulmonary artery and make PE, which is not good. If a cloth starts to form into arteries which supply heart muscle, there will be myocardial infarction. If it happens in brain artery, there will be an ischemic stroke. In these cases, we can administer drugs named "anticoagulants" (btw, please try not to name them "blood thinners" - they do not "thin" anything, they prevent clotting). Each of them works differently with different "F" factor(s) or with platelets which initiate extrinsic pathway, blocking their work in various ways. They can be "natural" (human blood contains chemicals very much like heparin but there is no way to boost their production in human body so far, so that medical heparin is made from internal organs of domestic cattle) or totally artificial like coumadin.

OK. Get me coffee (black, lots of sugar) and one for yourself, too, make yourself comfortable. There will be a long talk (and likely several posts). To do its job - to deliver oxygen, antibodies, cells, nutrition and all that, and to flow out various chemical trash, blood must stay within the vessels. Therefore, if a vessel gets a hole, it must be quickly patched so that blood won't leak. Also, if there is something sticking into or out of the vessel wall, this thing must be covered in some way so that it doesn't dusrupt blood flow. The two things above are, from the body's point of view, very important. To get them done, the body has several overlapping systems. The name for ALL these systems are COAGULATION CASCADE. Why cascade? Because it works like an avalanche in the mountains. Once one part goes on, it activates the following step and each following step goes the same till, from the point of the view of the body, problem is solved and problem blood vessel is CLOTTED off. And, in case of blood vessels injury, in is "good" thing. Otherwise, blood would just flow out and you'll die from blood loss after scratching your finger. You just saw above that, basically, there can be two causes why a blood vessel might need to be clotted: either it is injured and blood leaks out, or there is some injury on the vessel wall, like piece of fat (yep, those "cholesterol plaques" in vessels are just areas of yellow hard fat which stick out into the vessel). Therefore, there can be two ways to activate clotting cascade. They are named "intrinsic" which starts from damaged vessel wall, and "extrinsic" which starts from another tissue damage but NOT damaged wall.