The Nurse Practitioner’s Place

It’s time for Change of Shift over at Emergiblog! Enjoy…

Once again, Kim at Emergiblog has put together a great compilation of nursing stories at Change of Shift !

Patient Profile: W.D., 36year old female, married
Chief Complaint: “I am having some discharge and it itches”
History of Present Illness: Pt states no illness at this time.
Past Health History: Asthma. Ovarian cysts.
Past Surgical History: Tubal ligation 2001.
Family History:
Paternal Grandfather (88) Healthy
Maternal Grandfather (82) Deceased
MI
Paternal Grandmother (86) COPD Maternal Grandmother (68) Deceased Asthma, Sickle Cell Anemia
Father (65) Healthy
Mother (68)
Patient (36) Asthma

Current Health: Sulfa allergy. Denies drug and tobacco use. Drinks mix of soda, water and milk daily. Sleeps approx. 8 hours nightly. States moderate level of exercise due to taking care of 4 children.

Psychosocial History: Married, gravida 2, para 2 High school diploma. BCBS insurance. Works as cashier at this time.

Review of Systems:
States 2 successful pregnancies previously. Last pap smear done on 01/06. States no history of STDs. States menarche at age of 13 years. LMP 03/15/06 lasting 7 days with moderate to heavy flow. States regular cycles occur every 26-28 days. Does not use douche.

Physical Examination:
Vital signs: BP 117/62 Pulse 78 Resp. 20 Height 5’4” Weight 210

Normal distribution of pubic hair for age.
External genitalia dark purple colored and moist, with no varicosities, lesions, organisms. Noted redness of labias majora and minora with slight edema.
Thick, white, curdy discharge.
No swelling, tenderness, or discharge on palpation of Bartholin’s and Skene’s glands.
No masses, lesions, or anatomical deviations of the vulva and perineum.
Cervix smooth, moist, firm, and non-tender, slit sign noted. (previous pregnancy)
Vaginal walls are reddened, moist, rugose, without swelling or masses.
Uterus is appropriately sized for age and condition. Firm, pear shaped, slightly mobile and anteverted.
No tenderness. No lesions, nodules, masses, or bleeding.
Ovaries and fallopian tubes are nonpalpable.
No hemorrhoids, or painful areas on rectum.
Negative for kidney pain per percussion.

Medical Diagnosis: Candidiasis infection

Nursing Diagnosis:
Infection, r/t alteration in normal flora of vaginal canal, a.e.b. discharge and itching symptoms.

Patho:
Vulvovaginal candidiasis: This is the second most common cause of vaginitis. The patient’s history includes vulvar pruritus, vaginal discharge, dysuria, and dyspareunia. Approximately 10% of women experience repeated attacks of VVC without precipitating risk factors. The change from the normal, non-clinical presence of the fungus to a pathological attack may be the result of various factors. Antibiotics which influence the bacterial population present at any of the three sites may allow the proliferation of the fungus. Diabetes mellitus, pregnancy, malnutrition (including alcoholism) and, in the case of vaginal thrush, bath additives may contribute to the condition. Immunosuppressed and AIDS patients also readily contract it.
Physical examination findings include a vagina and labia that are usually erythematous, a thick curdlike discharge, and a normal cervix upon speculum examination. It is the extensive growth of the Candida species which produces inflammation, erythema and irritation. There is a school of thought that believes that recurrent thrush infections may be due to an excessive population of the normal intestinal flora of Candida species. It should also be borne in mind that systemic candidiasis, although rare, is a serious condition which requires referral.
Treatment and Education: Monistat vaginally x 7 days. The cream should also be applied to the male partner’s penis even if he is asymptomatic. Diflucan 150mg PO x 1 dose as alternate medication. Wipe from front to back. Increase yogurt consumption with active cultures. Avoid tub bathing if seems to be precipitating factor.

I knew going into a family practice that I would be the one doing the pap smears. In my job interview that was actually mentioned. That is one reason why I did several clinicals in an OB/GYN office. There was still a learning curve though. One tip.. don’t use too much lubricant. I was trying to make the process as comfortable as possible but had to redo a few due to contamination from it. Second tip.. Use a large enough speculum. The vaginal walls will fall too far into your line of sight if you use one too small. While this is a process that most women will tell you is NOT their favorite thing to do, a nurse practitioner can make the visit much more pleasant.

I introduce myself and ask all of the usual questions about dryness, vaginal discharge, menopausal symptoms, etc. BEFORE the patient gets undressed. I tell them that I know that this is not their favorite thing to do, but that I will try and make it as easy as possible. I leave them to get undressed and let my office nurse know that I’m ready to do the deed.

At this point, I walk into the room and say ” I know that you were hoping that I forgot about you!” in a joking manner to break the tension and start the small talk while I’m actually doing the exam part. I ask if they have been told that their cervix is tipped or turned to one side or the other before I go digging around. All the while, I’m talking to myself while I’m looking at the insides and asking if the patient is doing okay and whether I’m hurting her in some way.

The trick is in the small talk. It helps relieve the tension to distract the patient.
I can usually find some way to make them laugh.

I was actually told today by a patient “while I hate having to do this every year, you just made it fun because you have personality!”

How cool is that?

Hello to all! I have been pretty busy at the office and I rounded in the nursing homes this week. I saw 59 patients between the office and two nursing homes. WHEW!

I decided to start a new blog called NP Notes and put some of my nurse practitioner notes from school there. It’s a way to get some of the stuff off of my personal computer and hopefully help fellow students!

Let me know what you all think. I’d love some suggestions for content. While your at it, some suggestions for content here are always welcome too!

Patient Profile: J.W., 37 year old male, married, car salesman

Chief Complaint: “I’ve had a sore throat for a week and noticed white patches on my tonsils.”

History of Present Illness: Pt states “sore throat” started three days prior to office visit. Pt states that he has been “eating cough drops” to ease the pain. Upon noticing white patches, decided to come in for an assessment. Pt describes burning pain level 6/10 in the back of throat. Low grade temperature noted from previous evening.

Past Health History: Patient states chicken pox and roseola measles as a child with immunizations completed according to schedule. Past injuries include: “fractured” –femur at age of 12 and stitches to left hand at age 24. Past surgeries include: laparoscopic cholecystectomy (2000), and open appendectomy (2002).

Family History:
Paternal grandfather (72) deceased
HTN, DM (Type II) Maternal grandfather (77) alive
HTN
Paternal grandmother (69) alive
HTN, glaucoma, DM (Type II) Maternal grandmother (73) alive
Osteoarthritis
Father (56) deceased HTN, Lung Cancer Mother (58) Healthy
Patient (37) HTN, DM (Type II)
Brother (42) HTN, DM (Type II)
Sister (34) Healthy

Current Health: No known allergies. Denies alcohol and drug use. Smokes cigars (one pack of 5 daily). Drinks two cups of coffee in the morning and drinks water rest of day. States gets moderate exercise by walking daily. States sleeps approximately 8 hours nightly. States HTN and Type II DM.
Medications: Lotensin 10mg daily, Glucotrol 10mg BID, Glucophage 500mg daily, HCTZ 25mg daily

Psychosocial History: States happily married with two children. Owns home and works full time. Considers self lower middle class. Adequate insurance reported. Graduated high school. Never went to college.

Review of Systems:
General condition: States no weakness, fatigue, chills, or weight loss. States low grade temp since last night.
Skin, hair, nails: No changes in color, texture, chronic marks, pruritis, odors, alopecia or rashes.
Head and Neck: No headache, syncope, vertigo, or stiffness reported. States difficulty swallowing secondary to sore throat.
Eyes: Reports 20/20 visual acuity. Date of last exam 10/20/05, no reported itching, discharge or pain.
Ears: No reported pain, tinnitus, discharge or use of hearing aids.
Nose, Mouth, Throat, Sinuses: No epistaxis, discharge, pressure or congestion reported. No hoarseness or oral lesions reported. States sore throat and “visible white patches”.
Dentition: Date of last exam 09/12/05. No cavities filled. No missing teeth or dentures reported.
Breasts: No masses, discharge or gynecomastia reported.
Respiratory: No reported cough, dyspnea, sneezing, pain on inspiration, or shortness of breath at rest or exertion.
Cardiovascular: No reported pain, palpitations, edema, cough Last B/P 137/71
GI: No reported pain, nausea, vomiting, constipation, diarrhea, or indigestion
GU: No dysuria, hematuria, frequency, or incontinence
Genito-Reproductive: No reported penile discharge, lesions, prostatic problems, impotence, states sexual relationship with wife satisfactory.
Musculoskeletal: No reported myalgia, stiffness, swelling or deformity.
Neurological: No reported seizures, tremors, memory disorders, paralysis, paresthesia, weakness, or dizziness.
Psychiatric: No reported depression, anxiety, or mood changes.
Endocrine: No reported goiter, heat/cold intolerance.
Hematopoietic: No reported bleeding, bruising, anemia, blood type A+.
Lymphatic: States swollen tonsils with white patches and pain.

DX: Tonsillitis, Pharyngitis

Medical Treatment: Usually some kind of penicillin. Amoxil 500 TID x 10 days etc.

I’ve been very busy in the new office. One of the things that I’m hearing from my patients about various doctors is the complaint that they often feel rushed during their visits. This is nothing new because I heard it on a daily basis at the hospital as well.
I’ve been told recently that I needed to speed up during my visits with the patients at the office. While I understand the need to maintain productivity, I also have found that patient satisfaction is a little more important right now. Cases in point….

If a patient comes into the office complaining about various areas of numbness and weakness in upper and lower body I would check lab work which may or not be normal and ran the scenario by the doctor. These symptoms could be mistaken for a psychosomatic illness but I would decide to do an MRI anyway because my intuition would bother me. While it may be “all in the patient’s head”, it may be a brain tumor or multiple sclerosis.

Similar scenario..Pt complains of numbness and tingling in one arm. Pinched nerve versus brain tumor?

If I don’t take the time to listen to the patients thoroughly, without rushing them, I could miss diagnoses.

I’m glad that I didn’t..

Patient Profile: A.S., 28 year old female, married

Chief Complaint: “I’ve been watching a spot on my arm and I’ve noticed it’s changed shape.”

History of Present Illness: Pt states that she has been going to tanning beds for several years and has noticed a mole that has started to change shape and coloration.

Past Health History: No major illnesses. Cesarean section in 2002.

Family History:
Paternal Grandfather (72) HTN
Maternal Grandfather (71) HTN, DM
Paternal Grandmother (70) Healthy Maternal Grandmother (68) Deceased MVA
Father (66) Healthy Mother (65)
HTN
Sister (32)
Healthy
Patient (28) Healthy

Current Health: Sulfa allergy. Denies tobacco and drug use. States drinks 1-2 beers on the weekends. Drinks hot tea in morning and water rest of day. Sleeps approx. 7 hours nightly. States moderate exercise by walking and occasional aerobics.

Psychosocial History: Married mother of one child (4 yrs) Owns home and works full time as a cashier. Adequate insurance. Graduated highschool with no college.

Review of Systems:
General condition: States no weakness, fatigue, chills, or weight loss.
Skin: Denies any rashes, hives, bruising, or skin dryness. Denies any lacerations or lesions. States cesarean scar on abdomen. States mole on left arm 1cm with irregular border brown in color.
GI: No reported pain, nausea, vomiting, constipation, diarrhea, indigestion, rectal bleeding or change in bowel habits.
Musculoskeletal: No reported myalgia, stiffness, swelling or deformity.

Physical Examination:
Vital signs: BP 118/72 Pulse 68 Resp. 20 Height 5’4” Weight 160

Skin: Warm with good turgor. Intact with smooth texture. Pale pink in untanned areas. Scattered freckles consistently colored except for single brown mole 1 cm in diameter with irregular borders. Vertical surgical scar on abdomen from cesarean approx. 6 inches long.

GI: Slightly obese abdomen. Centrally located umbilicus. Surgical scar noted in lower abdominal quadrant approximately 6 inches in length. Silver colored striae noted scattered at lower abdominal and hip areas. Bowel sounds present in all four quadrants. No bruits in the renal, aortic, iliac or femoral areas. No visible aortic pulsations or peristalsis. Tympanic percussion in all four quadrants without pain. Liver palpated two fingers breaths below right costal margin. Spleen and kidneys not palpable. No herniations. No costovertebral tenderness noted.
Musculoskeletal: Posture erect with head midline. No kyphosis, scoliosis, or lordosis noted. Phases conform in gait. Weight evenly distributed, both feet straight ahead, no toeing in or out, all movements coordinated and rhythmic, arms swing in opposition, stride length appropriate. Balance intact. Patient can tandem walk, heel to toe walk, perform deep knee bend and hop in one place. Negative Romberg sign. Positive finger-thumb opposition, toe tapping and heel down shin. Full range of motion of neck, spine and extremities. Normal flexion and extension of upper and lower extremities. Strength 5/5 in all extremities.

Medical Diagnosis: Possible malignant melanoma. Referral to dermatologist for evaluation and potential removal.

Nursing Diagnosis:
Risk for altered skin integrity, as evidenced by neoplasm.
Risk for altered circulation, as evidenced by family history of HTN and patient BMI.

Education: Teach risks of sun bathing and tanning booths. Use of sunblock. Signs and symptoms of HTN per family history. Yearly checkups. Proper diet to encourage weight loss.

A reader asked over at Nurse Zone .

Dear Stephanie,

I graduated from an ADN program three years ago, and have been working as an RN in the pediatric unit since graduation. I’ve gone back and forth as to whether it would be worth it to pursue an advanced degree in nursing. Many seasoned nurses I’ve worked with have told me the hourly pay differential between an RN with an ADN, BSN or MSN is minuscule at best and sometimes nonexistent depending on the facility. If this is the case, can you tell me what the advantages would be for me to obtain an advanced degree in nursing? Thanks Stephanie,

- Elka

Stephanie Thibeault, RN, BSN and author responded:

Hi Elka,

This is an excellent question, and one that is often asked. Initially, there is very little difference in pay for diploma nurses, those with an ADN or a BSN. For new graduates, there is also little difference in job opportunities available. Many nurses wonder why, then, would it be worthwhile to pursue advanced degrees in nursing. The answer lies in taking a longer outlook—looking ahead to the changes coming to the profession of nursing, as well as the direction you would like to take to develop your career.

The profession of nursing is continuously evolving, along with all health care professions. Take physical therapists, for example. Ten years ago, physical therapy required a bachelor’s degree for entry-level licensure. That changed to a master’s degree soon thereafter, and a Ph.D. is now being phased in as the entry-level educational requirement. The educational requirements for registered nurses are also changing. Many employers, such as the Veteran’s Administration, are now hiring RNs with a BSN or higher exclusively. When nursing adopts the BSN as its entry-level educational requirement, those with a nursing diploma or associate degree will be grandfathered in, but job opportunities may significantly decrease.

What are the advantages for you to obtain an advanced degree?

* Expanded career options: Obtaining your BSN, MSN or even Ph.D. in nursing opens the door to more career opportunities. Nurse educators, case managers, public health and community nurses, research nurses and nurses in management positions are often required to have a BSN at minimum. The BSN allows for increased responsibility, career progression and greater career choices.
* Expanded practice or specialization options: Obtaining board certification in many specialties in nursing often requires a BSN. Advanced practice nursing career options, such as licensure as a nurse practitioner or nurse anesthetist, requires an MSN at minimum.
* Increased income: While entry-level RNs begin with roughly the same pay level regardless of educational level, an advanced degree can lead to increased responsibility, credibility and career options. These, in turn, lead to a higher income.

I hope this information has been helpful, Elka. With so many employers now offering tuition reimbursement for advanced education, and with a phenomenal increase in the number of accelerated degree programs tailored to working professionals, continuing your education is more affordable and flexible than ever. I wish you the best in your nursing career and advanced educational pursuits!

I absolutely agree with Stephanie regarding advancing your degree. We cannot afford to become complacent with our education in the medical field. Things are changing too fast and we must advance our profession as well.