PANYNP

7) If you have to draw blood on a super tough stick, look for superficial veins on the foot and use a 25ga butterfly. Caution: Check your State Nurse Practice Act before even thinking of phlebotomy or IV stick on a patient's foot. Task frequently is limited to anesthesia providers only.

Intended to say "punctate lesions", rather than "punctuate" lesions. Spellcheck, ugh.

Seeking expert wound care advice, as my home health agency neither employs nor consults with a WOCN. Patient was referred by PCP. Patient is a 62 yo well-nourished community-dwelling semi-retired moderately active non-smoking non-diabetic female with known venous insufficiency. No history of lymphedema. ABIs are 0.9 bilaterally. Pt presents with a 3-week history of a 10 cm x 5 cm area containing approximately 12 punctuate weeping lesions on her R posterior calf. She states this area of skin irritation with weeping began during a Prednisone taper following severe bronchitis. Pt was evaluated in Wound Clinic and was treated with Aquacel Ag and application of an Unna boot. Due to severe sensitivity to the zinc oxide component of the Unna boot, a recommendation was made to discontinue the Unna boot and continue with application of Aquacel Ag to affected area q other day, cover with ABDs, apply Eucerin to non-affected area, cover with one layer of Tubigrip foot to knee, and elevate extremity as much as possible. Pt states that Aquacel Ag and dressings become saturated with serous fluid within 3 hours of dressing change, with accompanying maceration and circumferential skin irritation at ankle. Pt is capable and compliant with carrying out her own dressing changes, but is concerned with lack of wound healing progress and required frequency of dressing changes, as well as cost of supplies. Looking for suggestions on alternative to Aquacel Ag or any other ideas to promote healing.

Namenda also is neuro-protective; not strictly for dementia. This individual may have been part of a geropsych registry and was being observed for neurological progress/lack of progress while on Namenda.

COB nursing professor here. Is it possible to take Stats at a community college this summer and transfer it into your program? Before you commit to doing this though, be 100% sure that your school will accept it as transfer credit. Agree with other posters that all three courses taken together would be doable, but it might not be pretty, particularly with 2 labs, and one additional course to bring you to FT status. Best of luck; welcome to the profession!

Our hospital's team of psych clinical liaison (psych CL) nurses, whose primary role is to tend to hospitalized inpatients related to emotional and spiritual concerns, also is available to groups of staff for critical incident stress debriefing, such as following a "bad" code, or issues with abusive patients or families. I don't believe I've heard about individual counseling, though, for all the reasons listed by everyone else.

My apples and oranges comment was intended as a response to Workinitnurfava who commented that an EMT should be able to transition to RN.

Totally different worlds. Apples and oranges. In fact, it might behoove OP to limit or eliminate entirely any discussion of her pre-hospital experience when applying for or starting a new position. Speaking as a COB former nursing faculty member, my colleagues and I typically dreaded having pre-hospital personnel (EMTs, other first responders) as students, both clinically and in the classroom. While we have unlimited respect for the work they do, it rarely is a seamless transition for a pre-hospital provider who enrolls in a nursing program. More than "not knowing what they don't know", there are different limits to professional autonomy. OP ultimately will be successful as a nurse. It takes patience and finding the right ego-free fit.

COB here. So very sorry that you experienced such a challenging and frustrating patient care situation that was exacerbated by what appeared to be a lack of support by an unsympathetic and unhelpful middle manager (nursing supervisor). I agree with others who recommended that you follow through with a request for clarification of the meaning and intent behind this nursing supervisor's remark. Her role ideally should encompass not only monitoring of functioning of patient care areas and patients' condition by assessment of nursing work conditions, but also supporting staff who are challenged by difficult and/or disruptive patient care situations. Although daily rotation of nurse caregivers disrupts continuity for patients, and may contribute to their increased anxiety while hospitalized, nurse caregivers' level of anxiety and risk for disengagement and development of compassion fatigue also are factors that must be acknowledged in order to maintain a healthy workforce of nurses who actually want to work as nurses. Recently a master's student who works as a staff nurse in long-term care related to me that her administrator told her that "residents have a right to fall". When I looked in the literature for a rationale for this statement, very limited anecdotal evidence was available that seemed to indicate that a failure to implement fall precautions was acceptable in that these precautions impinged on an individual's free will or "right to fall" (injury and liability notwithstanding). I wonder if the nursing supervisor's observation that "it is her right to abuse you" comes from a place of similar sideways thinking. In any event, an academic medical center in Western New York, where I spent many years in practice, has a MIPS service - Medicine in Psychiatry - that includes a 20-bed inpatient unit for patients with mental health diagnoses who also require inpatient hospitalization. In an ideal world, this setting may have been the right type of placement for your challenging patient. In the less than ideal world in which most of us live, I encourage you to continue to question and assess your patient care environment for safety and comfort (both patients' and your own), analyze your own responses to your daily experiences, and reach out to the community of nurses, both locally and globally, as you've done here, for solutions based in both practice and science. We're counting on you, as a young nurse, to maintain your passion for providing mindful patient care. Typically I don't say "namaste", but it seems to fit here. Namaste.

Preach, Sistah!

We gave verbal report and Still were out of there by 2320. Loved 3-11 when I was in my 20s: the party shift. We went out almost every night after work.

Machines are reliable as long as they are calibrated. Need to know how often biomed engineering comes around to check all devices on which we base patient management decisions, i.e. drips etc.

COB here. Does anyone remember using Kpads for treatment of DVT? Kpads were light green rubber heating pads that we would place inside a pillow case. They would be ordered from SPD, who would bring them to the floor. First, we would wrap the patient's legs from knee to ankle with long lengths of moist Kerlix, soaked in warm water in a small green sterile basin, then place blue Chux around the patient's legs on top of the Kerlix. Then we would wrap the pillow-cased Kpad around each of the patient's legs and hold it in place with additional lengths of Kerlix that we would tie in three places to keep everything held together. Warm and soggy. The order would read something like "Kpad to lower extremities, and elevate for 1 hour tid". This treatment was intended to improve venous return via warmth and elevation.

I'm not sure whether it's permissible to endorse a book on this site, but here goes. Take a look at Carolyn Buppert's "Nurse Practitioner's Business Practice and Legal Guide".

Re drip rates - if you travel as a volunteer on a health care mission trip, which many nurses do, to Central America or rural Africa, you will find yourself counting drops.

Congratulations on your new job! You want to keep in mind that when you go to recertify as an FNP, you will need to demonstrate that your work experience is in primary care, as that is your education and training. Have a plan for how you will address working in an acute care/critical care setting when you have been educated in primary care. Hospital systems will hire warm bodies to fill their slots, without concern for how these folks will maintain certification. There always is a liability issue hanging over your head if you are practicing outside your educational scope of practice should an untoward event occur. Perhaps some other primary care NPs who are practicing in acute or critical care can comment.

Oh - no, I'm not encouraging you to do an FNP program. Just attempting to note that there are differences between acute care and primary care training, as to where skills are best utilized. Re DNP: There are schools that have moved away from offering strictly master's degrees in favor of DNP as entry to advanced practice. There also are schools that have reversed this stance, and have returned to offering master's degrees as a terminal degree, in addition to DNP. I also teach in a DNP program (I'm a PhD NP) so from that perspective, I can say (my own opinion) that it still may take another 10 years or longer until the MSN vs DNP tension settles itself. In my geographic area of Western New York, DNPs are being employed as faculty members and doing a day/week of practice and FT practice during the summer in order to match the salary earned as a staff nurse, who can earn OT, holiday differentials etc. The few DNPs who are in practice (in my locale) in the hospital or affiliated clinics have the same starting salary and earning trajectory as an MSN-prepared NP or CNS - since you earlier had expressed concerns about earning potential.

Speaking as a faculty member in both primary care and acute care NP programs for the past 18 or so years... One of our primary care preceptors is an NP who graduated from an MSN program at a top-rated university in New England. Her prior degree is in graphic design; she had no health care experience prior to becoming an NP. When I have done site visits for students who are precepting with her, it's been fascinating, and a little unsettling, to observe her thought processes as she and a student work up a patient. It is very clear that her clinical perspective is different from an NP who has worked as an RN. Her viewpoint comes across as less holistic (i.e. less "nursey") and far more focused on the medical model of assess, diagnose, test, prescribe, document, onto the next patient. Scant attention is paid to the patient's home circumstances, socioeconomic status, family situation, employment - factors that affect general health and well-being, as well as potential for compliance with a health regimen - -nurse-y considerations. This NP provider is clinically brilliant, but seems (to me) to be a hybrid, rather than a "nurse" practitioner. More like a PA. Not that there's anything wrong with that, as JS would say. In relation to OP's acceptance into an ACNP program for non-nurses, I tend to agree with the poster who observed that to be able to walk into an ICU patient's room and immediately discern, from among drips, invasive lines, ventilator settings, and monitors, which of these supportive functions demands immediate attention, after looking at patient and cardiac monitor, requires experience gained as an RN staff nurse. Even outside an ICU, in a hospitalist model of care, inpatients are sicker and more complex than ever - some hanging by a thread, without the support of drips and vents. These patients, with chronicity and multiple comorbidities, can be just as complicated as ICU patients. Again, sorting out what to tackle first requires the experienced intuition/gut of a seasoned RN. Your ACNP program likely requires ~ 800 hours of clinical. I'm unconvinced that this is a sufficient practicum for the responsibility you will have when you've graduated and are ready to enter practice. You had mentioned working in an outpatient setting as well. Even in a specialty clinic, ACNP training may not be necessary. Many of these types of positions are filled by primary care NPs. One last comment, I promise. FNPs are educated to take care of individuals across the lifespan, from birth to old age, not just kids, as you've mentioned. There are many FNPs who work in LTC. My view, since you asked for feedback, is that an accelerated BSN, with a gap year of full-time RN work experience, followed by matriculation into the ACNP program would be ideal in your situation. Or PA school, since the medical model was your first interest back when. I'm a second-career person, as well. Best of luck to you.

COB here. I've had similar conversations over the years without suspension. In this case, I probably would have addressed the resident's BO, and a request for another type of deodorant with one daughter, though, rather than having a group discussion, which seems that it resulted in all-around embarrassment. I do agree with other posters who have said that resident hygiene is the ultimate responsibility of care staff. In the olden days, we would give Cepacol mouthwash baths to new admits in the ICU if they were particularly ripe-smelling. Did you receive a written notice of suspension with the reasons? If not, you want to request a copy of whatever has been placed in your employment file related to this situation. As well, if there also are additional comments regarding your conversation with the administrator about the glitches in the new computer program, or your communication style, then you will have a better idea of your standing. An employer who values employees will offer remediation, not just discipline (suspension), in order to improve work performance to their standards, whatever these may be. Otherwise, this response on their part is arbitrary, dependent on which way the wind is blowing that day. "Customer service" does sometimes cancel out common sense.

Here's my two cents on "nurture", although perhaps without an adrenaline rush. A couple years ago I had a freak trip-and-fall at home, and suffered a long laceration on a 3/4 circumference of my lower leg, requiring 20 sutures. The laceration wasn't healing well on its own because of the location between mid-calf and ankle. I ended up becoming a patient of the local university wound clinic. Imagine my surprise when I discovered that 3 of 20 RN staff members were my former BSN students whom I had taught only 2-3 years earlier. Each of these nurses told me that they had spent a few years working 12-hour shifts as bedside RNs in the university medical center, in Burn-Trauma, Pediatric ED, and CT Stepdown. When the opportunity presented itself, each wrenched themselves away from inpatient care for the structure of a 40 hour/week 0800-1630 clinic job. Their reasons included desire for a less fatigued life, better hours related to child care, and a desire to hang with friends and family who also worked regularly scheduled hours. These nurses are very bright and have become highly skilled in their wound and skin specialty. They are valued members of an interdisciplinary team consisting of physicians, NPs, a clinic-specific social worker, and available OT and PT consultants. They attend continuing ed offerings, have the same university benefits package as nurses at the hospital bedside, and although their hourly rate is ~ 12% less than what they earned at the bedside, each of these former students said they are happy and fulfilled in their nursing role. Seeing them carry out their expert nursing functions made my heart sing, from intake and preliminary assessment, to carrying out complex treatments, to providing patient education and telephone follow-up, as well as implementing and tracking performance improvement initiatives. For a prospective or experienced nurse who is seeking a position where there still is room for "nurture" without undue time-related pressure and craziness, it appeared to me that this type of clinic nursing would be a great job. Because the clinics are part of the university medical center, minimum RN requirement is a BSN. Interestingly, over time, I have run into other former students who work in sleep clinic, derm clinic, ortho clinic, and HF clinic, among others. Busy, fulfilling work on a more regular schedule, for those who are fortunate to live near an academic medical center. As an aside, I worked 12-hour nights in the ICU while I was a grad student in my late 30s. Hated 12-hour shifts with a purple passion; loved 3-11 shifts (the party shift) back in the olden days. We were able to get things done in 8-hour shifts; it takes pacing oneself. The older and more achy we become, the less desirable are 12-hour shifts. Just saying.

Wow, just wow. There is way more to LTC than the tasks you've described when taking care of "frail and forgotten Geri's"!? I am a COB, an old ICU nurse from the trenches. I became a Gero NP in my late 40s, and I use all of my finely tuned assessment and management skills from years in the ICU to discern symptoms of stroke, HF, resp failure, "dwindles" or failure to thrive, exacerbation of MS and an assortment of other neuro maladies, ortho problems, arthritis, allergy, falls and fractures, skin issues, pain and symptom management, and EOL care. And more. I work as a team member with CNAs, LPNs, RNs, a part-time medical director, community attendings, consultants, pharmacists, nutritionists, social workers, and one other NP. My workplace is a 188-bed continuing care community with 5 separate residential units ranging from transitional (subacute rehab) to a locked memory care unit, with a few hospice beds scattered throughout. I am on the run from 0630 to 1630 daily, (high speed, split second) with admission workups, ensuring safe discharges to home, small booboos, big catastrophes, insulin orders, antibiotics, antihypertensives, antiarrhythmics, side effects of these meds, interpreting 12-leads, making decisions when to send residents out - considering the functional decline that takes place when older individuals are hospitalized, or putting together a workable plan to keep the resident within our community to the extent that we can handle, related to IV hydration, IV morphine etc. Although your advice to OP started out well, it turned a tad murky toward the end as you question why a BSN would work as a staff nurse in LTC. Why not a BSN, if that's the niche and comfort zone. My sense is that even though OP stated that LTC nursing is "lame", her listing of her skills demonstrates just the opposite. Seeking reassurance and reaffirmation is fine. And sometimes necessary. Anyone who works in adult acute care knows that Gero is where it's at, baby. And it's going to stay that way into the 2060s, when the last of us Baby Boomers shuffle off this mortal coil. As nurses, we value individuals from the cell to the spirit. Love ya, mean it.

Your writing touches my heart, and I am reassured to read of your continuing devotion to patient and family-centered care at the bedside. You are a model for why the profession of nursing continues to rank highly in advocacy and ethical practice. As an NP and academic faculty member, though, I am dismayed that part of your decision against enrolling in an NP program was based on an impression of brief patient encounters and order-writing as carried out by advanced practice providers in an emergency department setting. Primary care nurse practitioners, those who are didactically and clinically educated to serve patients in office practices, clinics, ambulatory settings, college health, or LTC, as examples, are responsible for managing patients with episodic and chronic illnesses. Their functions include assessing, diagnosing, ordering tests, and prescribing in a holistic context, based on best available evidence. You might suture, interpret films, and cast one day, and help patients with pain and symptom management, smoking cessation, weight loss, drug dependence, or general health promotion, such as updating immunization schedules another day. You also might practice in home health or hospice. If you practice in an office or clinic or LTC, you will build lasting relationships with patients and families as you help them navigate their illness-wellness continuum. One type of nursing is not necessarily more important or prestigious than another. We know that the beauty of nursing is in its varied opportunities for service to humanity. As another poster said, you want to feel content and confident in your nursing role, without having to justify your preference, wherever you may be. We are in this together.

I'm dismayed that people at your high school are trying to direct you toward a university that doesn't offer your major, based on prestige alone. What are the financial comparisons between UCB and Sac State? Are there other family or social considerations that would have you favor one school over the other? There is a school of thought that says it doesn't matter from where you earn an undergraduate degree, but it's more important to obtain your advanced degrees from a high name recognition and rigorous institution. In your case, perhaps Sac State, with excellent grades for undergrad, and UCSF or UW or OHSU for graduate work. Best of luck!

ABSN stands for Accelerated BSN. Typically done by folks with a prior four-year degree in another discipline, after science, math, nutrition, psychology prereqs have been completed.

My hospital, a large academic medical center, actually does not post all the available nursing opportunities. Nurse Recruitment operates under the assumption that it "looks bad" or "unsafe" if the population in the surrounding metro area can perceive that the hospital is short-staffed of nurses. (Which it is, chronically). Safe to say that it is a good idea to call or email Nurse Recruitment at a hospital where you're interested in working. Availabilities seem to be fluid and change on a daily/weekly basis.