started clinicals, need advice

allnurses Guide · Jun 14, 2014

Are you struggling with the clinical aspect or the didactic?

Qka · Jun 14, 2014

Well, i think both... Let me give you an example. The other day we had a diabetic patient on oral agents. Her FBS was in low 200s, not well control and we needed to adjust her medicine. She had tried some OA in the past, which did not work for her for one reason or another. E.g. did not lower BS to desirable level, had side effects or cost, not covered by insurance. I felt like we are triying just randomly to pick up OA that works for BS and satisfy her needs. But there should be some algorithm, shouldn't it? The recent medicine were very new, I have not heard about some of them at all. I do not know their cost or insurance coverage. Yes, I have Epocrates. In class we did not cover diabetes at all yet, I am just 5 weeks into my first clinical semester. So my knowledge is basically from my BSN education and experience. And being a hospital nurse, I mostly deal with insulin, not OA.

I realize that it becomes easier with experience and the more I get covered in school. But at my current level, what advice is helpful for me?

Diabetes is just one of them. HTN, lipidemia are other popular diseases in primary care. Or antibiotics.

I hope you see what I mean.

allnurses Guide · Jun 14, 2014

Well, i think both... Let me give you an example. The other day we had a diabetic patient on oral agents. Her FBS was in low 200s, not well control and we needed to adjust her medicine. She had tried some OA in the past, which did not work for her for one reason or another. E.g. did not lower BS to desirable level, had side effects or cost, not covered by insurance. I felt like we are triying just randomly to pick up OA that works for BS and satisfy her needs. But there should be some algorithm, shouldn't it? The recent medicine were very new, I have not heard about some of them at all. I do not know their cost or insurance coverage. Yes, I have Epocrates. In class we did not cover diabetes at all yet, I am just 5 weeks into my first clinical semester. So my knowledge is basically from my BSN education and experience. And being a hospital nurse, I mostly deal with insulin, not OA.
I realize that it becomes easier with experience and the more I get covered in school. But at my current level, what advice is helpful for me?
Diabetes is just one of them. HTN, lipidemia are other popular diseases in primary care. Or antibiotics.
I hope you see what I mean.

There are guideline algorithms for major chronic illnesses, including diabetes and hypercholesterolemia that you mentioned, and you should begin to familiarize yourself with them. As you gain more experience you will learn to tailor those guidelines to individual patients, but starting out, guideline management is the best way to go. At your stage I would expect you to know what was normal and what is not and what goal you are aiming for for the patient. In a few months I would expect you have some ideas about how to get there.

Your biggest challenge as an experience inpatient RN is learning to stop thinking like and inpatient RN. A blood sugar of 200 equates to an A1C of about 8.5%. How can you safely lover that 1.5%? You don't have to change it overnight.

At your level I would expect you know normal from abnormal and have some ideas of ways to fix it.

Qka · Jun 14, 2014

Thanks for your input.

NaShaH · Jun 25, 2014

Any body know if the patient not used his medication because of cost. What we should do for his HTN? Diet, only monitor him or give him generic RX?

allnurses Guide · Jun 25, 2014

Any body know if the patient not used his medication because of cost. What we should do for his HTN? Diet, only monitor him or give him generic RX?

Generic antihypertensive would be the first choice along with continued lifestyle mods and continued monitoring.

lhflanurseNP, APRN · Jun 25, 2014

Any body know if the patient not used his medication because of cost. What we should do for his HTN? Diet, only monitor him or give him generic RX?

You can also use programs through Walmart, Publix, etc. that provide certain HTN meds at little to no cost.

Dranger · Jun 26, 2014

Metformin or Glypizide and lifestyle changes should lower a A1C levels at least a few % before jumping into insulin.

ACE inhibs are good first line meds for DM as well as ARBs. What has his BP trend been?

Basic Zocor or Lipitor for hyperlipidemia, watch for muscle pain....

You should invest in Uptodate.....

PG2018 · Jun 26, 2014

I would examine the top 200 drugs list and pick from those what you feel you'll be working with. If you're not going to see psych patients, for example, then you could probably several of the top, lol. Interestingly, I covered this kind of stuff in my "advanced pharmacology" course which was shared by the psych NPs, family NPs, adult NPs, and peds NPs. It doesn't relate specifically to my practice area so it's all pushed to the back of the brain covered in cobwebs now, but I recall working in med-surg while taking the class and thinking "What the deuce?! Those docs aren't following any of the newest guidelines." That applied to DM, HTN, you name it. As an aside, I see a lot of med misuse in psych, lol. Medicine has become highly algorithmic (to cut costs) so what you're looking for is out there. Epocrates is great, (the paid one is best and I recommend it and have it), but it has its limitations. I'm not a subscriber, but I HIGHLY recommend American Family Physician by the American Academy of Family Practice. When I start working as an APRN I'm going to subscribe to it even though I'm psych. It comes out twice a month, and access can get you an electronic version which you can now search by an app. I just Google through old articles and printed out a couple last night; one on the abdomen and one on sinusitis. I just like knowing stuff. Uptodate is also good.

NaShaH · Jun 26, 2014

My question is about the best intervention as Np for this type of problem,this is part of certification exam .

NaShaH · Jun 26, 2014

Boston fnp thank you for your respond.