Questions for NP's that precept

[AMD88]

I am in an ACNP program now (only in my second semester)...I'm going to start clinicals next spring in internal medicine inpatient with a great preceptor who is very very busy. I want to know what I should be doing now to prepare for clinicals. I started making a list of common diagnosis I see in the hospital and I thought that reading up on them on uptodate might be helpful to learn what labs/diagnostic test/medications are normally ordered. Does this sound like it would be helpful? Is there anything you wish the np students you precept would focus on more before they start clinicals?

[Corey Narry, MSN, RN, NP]

I precept ACNP students on their Adult Critical Care rotation. Our field shares many similarities with In-patient IM or Hospitalist in terms of approach to patient care. We see a broad range of presentations involving any body system and the differential diagnoses could be wide in many instances. It is your role to play "Sherlock Holmes" if you will in deciphering what is wrong with the patient. Luckily, you have the luxury of ordering work-ups and have results available within minutes to hours in the in-patient setting.

Having said that, it does make sense to brush up on common diagnoses, work-ups, and treatment that you may encounter. However, I would caution you to not allow this knowledge to get you sidetracked in quickly assuming a diagnosis without having gone through the process of differential diagnosing properly. To get good at the process, you must have an organized thought process.

Start with a thorough history and physical. Be alert to pathognomonic cues. Pick apart lab results beyond looking at the basics of CBC and electrolytes. For example, investigate a low Hgb/Hct further by looking at the MCV and proceed with further work-up from there. Be aware of various patterns of LFT elevation that could signal one problem over another. Be able to synthesize all these data into forming in your head what possible pathologic processes are going on before proceeding with further testing.

I also find some NP students struggling with presenting their patients with a team. I think a lot of it has to do with the intimidation factor and "pimping" that happens on rounds. The best way to approach this is to just relax and know that you are there to learn but always be prepared and organized. You can follow the H&P form in terms of the sequence of your presentation if it's a new patient. In patients known to the team, you can start with overnight events then your exam, then your assessment and plan.

You should arm yourself with good references materials. While uptodate is excellent, it doesn't always rise to the challenge when you have a specific question that needs an immediate response. I like to use this reference: Hospitalist Handbook. There are similar versions of it like this one: Pocket Medicine.

Lastly, be humble enough to admit your shortcomings, always ask questions, show interest and enthusiasm. Never give the impression that you know it all. It's one thing to be able to impress your preceptor about your knowledge but never cross the line of being cavalier and annoying. It sounds pretty common sensical but you won't believe how many NP students make that mistake and cost them a future job prospect.

[AMD88]

I have to do an adult critical care rotation too but I'm going to do that towards the end of my program so I'll probably be hitting you up for more advice as that gets closer. I'll definitely focus more on interpreting labs. I'm taking patho now so this is a good time to work on that. Rounds will definitely be intimidating for me because I've never had to do anything like that before. I work on a neurosurgical floor now and I'm trying to move to the ICU. When I float to the ICU the nurses are involved in rounds so hopefully that will make it less intimidating. I'll definitely buy the hospitalist handbook before my internal med rotation. Is there a particular book that would be helpful before I do my critical care rotation? I am also doing a cardiac and neurosurgery rotation. I already have the books I used to get my neuro certification to brush up on before my neuro rotation. Cardiac is my weak area so I planned to find a good handbook to review before starting that rotation.

I'll definitely be humble. I'm very down to earth and I know the annoying "know it all types" and that's not going to be me!! Luckily, I've picked all my preceptors and I already have a good relationship with them so that should help with the intimidation factor. I just want to do well because I want to learn a lot and not slow them down. I also want them to want to hire me when I finish. Thank you for all your advice. Your response is very helpful!! I've read tons of ACNP threads on this website and I always see your post and they are really helpful.

[ChronicSG]

Juan here is the man! Always look for him when I'm trying to answer my questions about ACNP! haha