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Struggling NP student

NP Students   (24,957 Views 29 Comments)
by lvICU lvICU (Member)

lvICU has 9 years experience and works as a SICU RN.

5,158 Visitors; 118 Posts

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lvICU has 9 years experience and works as a SICU RN.

5,158 Visitors; 118 Posts

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There are 3 types of presentations that are used in Medicine: Admissions, daily, or ICU

Obviously admission notes and presentations should be very detailed as should ICU. Daily presentations should NOT. Only ICU notes should be by system.

I am assuming ivICU is presenting for general floor patients who have been in the hospital. That presentation should be in the SOAP format.

Dissent, thanks for the info on the patient presentations. I am actually presenting on ICU patients only. I am doing pretty well on the actual presentation part. My plan is what needs the most help (I have never been told this, it is just my self-evaluation).

I also struggle when I am asked a random question about a lab or disease process during rounds. The physicians don't always ask a question that is completely pertinent to my patient so it is sometimes hard to be prepared, although I try to be ready for anything. I have trouble thinking when put on the spot like that. I will continue to work through this though. Again, thanks for the info. I can use all the help I can get :D

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core0 works as a Liver transplant.

8 Likes; 15,476 Visitors; 1,811 Posts

Dissent, thanks for the info on the patient presentations. I am actually presenting on ICU patients only. I am doing pretty well on the actual presentation part. My plan is what needs the most help (I have never been told this, it is just my self-evaluation).

I also struggle when I am asked a random question about a lab or disease process during rounds. The physicians don't always ask a question that is completely pertinent to my patient so it is sometimes hard to be prepared, although I try to be ready for anything. I have trouble thinking when put on the spot like that. I will continue to work through this though. Again, thanks for the info. I can use all the help I can get :D

Another thing that might help is to have a A/P for every system. One of our attendings teaches the residents to have a diagnostic and a therapeutic differential for each system. For example if you have a patient in shock you would list what the differential in and then what tests you would do to rule in or out the differential. Then for treatment you would list what the different treatment options for the differential are. This allows you to think about the different processes going on with the patient. Also some of the differential may already be done so you can include that but state the test is already done and what the results are.

For example shock. MAPs 50's.

Diagnostic differential - hypovolemic vs cardiogenic.

DDx - Echo yesterday showed EF 65 percent with normal wall motion. Check if patient is volume responsive. CVP is 12. Vigeleo placed for SVV.

Then SVV 20 with CO 7 CI 2.5 showing adequate cardiac function.

Therapeutic intervention Bolus with NS to so SVV

Even if you can say its not a particular process this method forces you to think why its not or what piece of information you have that rules it in or out. Then if someone asks you a question you can discuss the process intelligently.

As far as notes, we are using a hybrid note. Our PE is system based but our A/P is problem based. This is strictly a billing issue. Our coders want the notes to have a problem based system. They were getting claims rejected because the problem billed on was not spelled out for the insurance companies. I still present the problems in a system based approach, I just write the A/P in a problem based format.

I'm a PA in a tertiary SICU.

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sandnnw has 20 years experience and works as a Emergency NP, NP Walk-In, USAF Reserve.

6,159 Visitors; 349 Posts

Your level of anxiety is perfectly normal. I can remember standing in front of an Pulmonary/CC or Cardiology Attending, several per day/week, helping present and discuss ICU patients. There was a fellow, third year IM, intern, medical student, DPharm (usually with a student), RN (usually with a student) and LCSW, Case Mgr and Service NP or PA. This team can be a bit intimidating until you begin to realize, they are all there for a reason, the patient. Not to poke fun at you or ask silly questions, despite the looks on the faces you may get (rare). They understand where you are at and hopefully where you will be in a few years. Think of this as an opportunity, as most NP/PAs do not get this kind of experience.

Take the advice of these good folks and whatever you do, don't forget:

introduce new team members, guests

review cultures/path results

how long a tube has been placed, specifically those in a vein or artery

asking for further questions, suggestions

close the door to the room, family loves to listen (and often misunderstands)

Get through this, work on improving your style and template. After a while, you'll know what's important (and what's not).

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Dissent, thanks for the info on the patient presentations. I am actually presenting on ICU patients only. I am doing pretty well on the actual presentation part. My plan is what needs the most help (I have never been told this, it is just my self-evaluation).

I also struggle when I am asked a random question about a lab or disease process during rounds. The physicians don't always ask a question that is completely pertinent to my patient so it is sometimes hard to be prepared, although I try to be ready for anything. I have trouble thinking when put on the spot like that. I will continue to work through this though. Again, thanks for the info. I can use all the help I can get :D

Well then scrap basically everything I said about presentations. In the ICU as Juan said, it is 100% by system- Basically SOAP format per system.

The "pimping" is really just to help teach you. I know it can be very anxiety provoking but once you realize you are not supposed to know everything, you will start to relax and everything will go smoothly. On rounds they are specifically trying to push you to the limits of your knowledge so that you can learn. If they just tossed you softballs all day long you'd learn nothing. They want you to take a step back and a give yourself a second to think before speaking and showing your thought process. They'll know you are bright and if your thought process is wrong, they will guide you through the rest. Just realizing they are not out to get you is more than half of the battle.

Good luck

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juan de la cruz has 27 years experience as a MSN, RN, NP and works as a Adult Critical Care Nurse Practitioner.

525 Likes; 3 Followers; 8 Articles; 57,378 Visitors; 3,747 Posts

give yourself a second to think before speaking and showing your thought process.

That's a good piece of advice right there.

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CCRNDiva has 7 years experience and works as a ICU Charge RN.

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Well then scrap basically everything I said about presentations. In the ICU as Juan said, it is 100% by system- Basically SOAP format per system.

The "pimping" is really just to help teach you. I know it can be very anxiety provoking but once you realize you are not supposed to know everything, you will start to relax and everything will go smoothly. On rounds they are specifically trying to push you to the limits of your knowledge so that you can learn. If they just tossed you softballs all day long you'd learn nothing. They want you to take a step back and a give yourself a second to think before speaking and showing your thought process. They'll know you are bright and if your thought process is wrong, they will guide you through the rest. Just realizing they are not out to get you is more than half of the battle.

Good luck

I didn't think about that. That is great advice. It never occurred to me that they are pushing the limits to facilitate learning instead of just testing her current knowledge. This tidbit is going in the vault!! :yeah::yeah:

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rnsrgr8t works as a Pediatric Nurse Practictioner.

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The anxiety you feel is normal. You are adjusting to a new model of care and it is hard, especially when you are used to being the "expert" in your field and comfortable in your RN role. The points given in the previous posts are very good. The "pimping" really is for your benefit to help you learn to think critically and on your feet (very important in the APN role you are pursing). Remember though, it is ok to say you do not know if you don't, especially if you give yourself a second to really think about the question. I had plenty of times in grad school where I got asked a question in clinical and, after taking a second to think, I would be honest and tell them I did not know! You have to be prepared to do your follow up research/reviewing texts etc to make sure you DO learn the answer. They do not expect you to know everything. You are a student. Relax, have confidence in yourself and your abilities and you will be fine. Good Luck!

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newyorkgroove works as a Wound care nurse..

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I am in my next to last semester of NP and I feel the same as you I've never liked clinicals, hated them, actually, but NP school is especially bad because of the number of hours you have to spend on them. I have also found myself trying to find reasons not to go, last semester was terrible. I did clinicals three days a week and worked every weekend and it was really messing with my mind. If we can hang on I think we will be glad we did, though I don't know that I really care for the primary care specialty, which is what my program is. Same old thing, accommodating drug seekers, watching some sweet little old person deteriorate more with each visit. Don't know that it's for me, but I've gone too far to jump ship now.

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lvICU has 9 years experience and works as a SICU RN.

5,158 Visitors; 118 Posts

Well then scrap basically everything I said about presentations. In the ICU as Juan said, it is 100% by system- Basically SOAP format per system.

The "pimping" is really just to help teach you. I know it can be very anxiety provoking but once you realize you are not supposed to know everything, you will start to relax and everything will go smoothly. On rounds they are specifically trying to push you to the limits of your knowledge so that you can learn. If they just tossed you softballs all day long you'd learn nothing. They want you to take a step back and a give yourself a second to think before speaking and showing your thought process. They'll know you are bright and if your thought process is wrong, they will guide you through the rest. Just realizing they are not out to get you is more than half of the battle.

Good luck

Thank you so much for this advice. It really puts things into perspective and I think if I keep this in mind, I will be able to relax a little on rounds and then maybe my brain will not "freeze up" :D

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788 Visitors; 13 Posts

We all feel anxious in NP school. It is exhausting. What people don't tell you in NP school is that you are learning to practice medicine. The learning curve is great. I had to turn off the nurse role and change gear to medicine. Study hard and arrive at your clinical 15 minutes early. This allows you to get relaxed, talk to people and read up on diagnosis d' jour. Now think what you would do if you did not have any nursing experience? Consider this, you have more knowledge and experience than a first and many second year medical students. Trust me, things start to click about 6 months after you start working. If you are in a clinical with a MD it can be awful. You are a coming threat. I found it easier in my training to have a NP as my preceptor. You might want to change that in the hospital setting. NP's are A+++ personalities. We hate failure. However, I willed myself in to practicing medicine. Nursing is a small piece of the NP training. Schools stick it in under community health and education. They want to keep reminding you that you are a nurse. Duh. Don't be suckered into this trick. NP has little to do with nursing except to get your job done you work with them. Once I understood my new role, I approached it differently. It also helped me understand why doctors get ******-off at nurses who don't get labs/lab results on time to their office. It gets intimidating but...darn it all it makes sense.

Then when you do work in the hospital setting as a nurse practitioner you know the reality of nursing. You know to expect a nurse to turn a 300 lb person in bed every hour is not going to happen. You were there, done that. So your orders are more nurse oriented to reality. Turn the 300lb patient every 2 hours and get a clinitron bed. You order CBC qd. When the doc freaks because it was not done by 7am, you know the nurse has 24 hours to get done. You don't fret. You have been there, done that. You are enlightened with information that doctors don't have... You are the NP. You know both sides of job. Your are going to do well. Keep friends with the nurses, they are your best friends. They do not want you to fail. Let them help you with information regarding patients. LISTEN to them. Congrats.

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missvictoriat has 5 years experience and works as a STAFF RN.

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Thanks for the encouragement! The "thinking clearly" problem is also where I get stuck. I can usually work through things in my head or on paper but when put on the spot in rounds I freeze up pretty bad. Then, I feel like an idiot and that doesn't help matters...I am just trying to keep a positive attitude and keep on trucking :)

Carachel: I have not done outpatient because I chose to do a critical care specialty with the ACNP program. In hindsight, I may not have chosen this route as I don't think that it suits me well. Part of the problem is that we do not have a set preceptor and we rotate units every few weeks. I have anxiety about meeting new NPs, attendings, residents, blah, blah, blah. It is a combination of many factors. I don't think it is my thyroid because I had it checked a few years ago, but thanks for the suggestion.

@ IVICU - WOW! What a challenging specialty to venture into! CRITICAL CARE with the ACNP program! I tilt my hat to you! You have come this far, BELIEVE IN YOURSELF! You will do well!

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1 Like; 17,707 Visitors; 1,840 Posts

OP - thank you for starting this thread. I haven't started my program yet, but I am bookmarking this thread for when I do.

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