Articles, Blog

5 Steps to Make Your Plan of Care for New Nurse Practitioners (Plus 2 Real World Tips)

November 22, 2019

Well, hey there It’s Liz rRohr from Real World NP and you’re watching NP Practice Made Simple– the weekly video is to help save you time, frustration, and help you learn more, faster so you can take the best care of your patients So I I apologize I’ve got a little bit of laryngitis today But moving on– I wanted to take a pause on the lab Interpretation series today to address an issue that’s come up in the last week with a lot of new grads I’ve talked to. And that’s the issue– and the question of– coming up with a plan of care. So whether or not you feel super strong with your differential diagnosis Or if you’re feeling it a little bit shaky– or very shaky– that’s totally okay. Making the leap between the differentials and the plan of care can kind of feel like you’re coming up drawing the blank– So I wanted to tell you today about the steps that I take and that I recommend you do To help you feel confident in your decisions. And also make sure that you’re not missing anything. I’m also gonna add two kind of “real world” tips about making plans of care And you may find that you need to go through this yourself and come to your own conclusions But if I can help save you a little bit of frustration, that would be awesome. So there’s five steps here. So step number one is coming up with your red flag diagnoses And so for red flags that what I mean are the different differential diagnoses that if you miss them, it would be really bad So those are things that are life-threatening and could kill you So it’s really important to come up with those differentials. Like what are those possibilities and work on ruling them out and so kind of a side note to this number one is that if you don’t have ready access to the tools that you need or The tests that you need to do to rule them out like an abdominal CT to rule out appendicitis They need to go to the ER– like that is super easy. So, you know step one Differential diagnosis. Is it life-threatening? Do you have the tools to roll it out? Yes Then you do those and if not, then you send them out. So step number two is The best way that I recommend kind of coming up with your plan of care– the place to start– is an algorithm. So And this comes back to your resources So I have two resources that I super love and these are in the resource guide if you haven’t gotten a copy yet And I don’t get paid to tell you this I just super love them. So number one is up-to- date– I’m such an up-to-date junkie– and number two is symptom to diagnosis It’s a really awesome book that literally just takes a symptom and brings you down the path diagnosis So a note about the algorithm kind of workup that you’re gonna choose I posted this a little note about this on Instagram and Facebook if you caught it already, but if not, there’s a common medical adage saying that goes, you know, if you hear hoofbeats think Horses and not zebras and so you want to start with common things that appear commonly Additionally, you also want to think about the pertinent positives and negatives So when I was in school if you had a symptom like a cough you made a table of the pertinent positives Symptoms and the pertinent negatives and that for each differential diagnosis and the one with the most pertinent positives Was kind of more the path that you would lead down So so yeah, so step number one is red flags Sending to the ER if you need to, step number two is choosing the algorithm from our resource that you really love and trust Acknowledging that common things appear commonly– and trying not to chase those rare zebra rare diagnosis Although it’s tempting and super fun . Number three– and this can be a little bit scary– But you kind of just have to put a stake in the ground and just choose, you know, you have to pick one diagnosis that you’re like, you know what I think that this is the diagnosis. So if I can give an example of it, so if you have a kid with store throat He’s 22. He has a fever of 100.7. He’s got a tender cervical lymphadenopathy He’s got a little bit of a runny nose. He doesn’t have a cough. He doesn’t have a rash He doesn’t have any exudate on his tonsils when you do an exam. He doesn’t have any ear symptoms, nausea, vomiting, diarrhea– Everything else is basically normal So if you’re thinking about this kid, the red flag diagnosis that I would choose to to investigate and make sure that it was not Number one is strep pharyngitis That would be pretty bad if you missed that Number two is mono. So mono is a virus and will self-resolve, But if somebody didn’t know they had mono and then I got a spleen rupture. That would be pretty bad And so the third one is a peritonsillar abscess. And so if you haven’t heard of this, I would definitely like google it or Look through your resources to learn a little bit more about it But that’s like an abscess that goes around your tonsils and that tends to have like a high fever severe neck pain And you can have a deviation of your uvula So for him those are the red flags The algorithm you’re kind of gonna consult your resource of like how to work those up and how to rule out those red flags and then number the step number three is you kind of just have to put your stake in the ground in so I don’t know if you’re familiar with the Centor criteria: C-E-N-T-O-R I can put a link below this video to reference it if you haven’t seen it already But that has to do with strep pharyngitis and the criteria that is suggestive of a strep pharyngitis Whether you can treat them whether you should do a throat culture or whether or not they probably don’t have it So for him and there’s either four or five criteria, depending on which tool you’re using and I’m referencing the the four step tool here But if he has a fever tender cervical lymph adenopathy no cough and tonsillar exudate That’s a four out of four and then you treat them if they have a three out of four You can either consider treating them or sending out a throat culture and then if it’s two or less Theoretically you cannot do a throat culture But I’ve seen people do throat cultures based on kind of like a hunch and that’s another discussion for another time But so for step number three, you’re going to commit like you know what? I think this kid has strep so You know put your stake in the ground and you’re going to come you’re going to treat them treat him and educate him based on that diagnosis And so you’re going to review, you know, I’m gonna give you penicillin twice a day for ten days. Take it the whole time Even if you’re feeling better drink plenty of water Take tylenol and motrin if you need to, saltwater gargles– things I should probably be doing right now [laughs] And then if you’re not getting better You should be getting better in the next 24 hours. And if you’re getting significantly worse You have high fever, shaking chills Nuchal rigidity, like you should probably be seen in the ER because there’s a chance you could have like a peritonsillar abscess You know, otherwise he should be on the trajectory of getting better and better in the next like week or so And so if he’s not then he should come back So those are the things you want to counsel the patients on that’s step number three Deciding the diagnosis and then counseling them appropriately Reviewing those alarm systems– and alarm signs and symptoms and when he should come back So step number four, sorry about that. So I actually just kind of combined step three and step four So step three is kind of putting your stake in the ground and step number four is like the education the alarm signs and symptoms so the alarm signs and symptoms the Education of when they should come back if they’re not feeling better, just being really clear about that because that’s really gonna protect you in case When you said that this was strep and it’s not actually strep. It’ll actually come back and seek further care and know to do that And then step number five is say like a week later You get a phone call or you see the patient again in the clinic that like, you know what I’m feeling a lot better But I’m still not totally better and I have like this new symptom like you’re gonna go And take yourself all the way back to the algorithm that you saw before about working up a strep– a sore throat — and kind of take the next best option Making sure again then it’s not a red flag and then moving on to next most common diagnosis and going from there So so those are all the five steps. So a disclaimer that I want to make here is that um, so I had a patient in my last clinic who came in for the first time with a sore throat and was treated for a Viral pharyngitis Suspected and then she kind of kept coming back– as she was directed– she either came back two or three more times after that But I think on the second time She was diagnosed maybe with allergic rhinitis, like a post nasal drip sore throat versus like a GERD sore throat and um, but at the same time additionally she was sent to ear nose and throat because based on her pertinent positives and negatives they weren’t Super clear. It wasn’t like absolutely this is reflux related– Absolutely this is allergy related so like You know what? Like let’s just he ENT the ear nose and throat Specialist and get another set of eyes on this and you know what it ended up that that patient had cancer, had throat cancer. So something to think about For yourself and it’s not to scare you. I should back up and add a disclaimer that I used to be an oncology nurse so I think that all patients have cancer until proven otherwise but so yeah, it’s not to scare you, but it’s something to keep in mind that like Like it’s a fluid process of like the red flags Matching things up based on the pertinent positives and negatives and the most common options but like listening to your gut Feeling of like this doesn’t really make sense And like let’s just make sure that she doesn’t have anything else going on or he doesn’t have anything else going on So the two real-world tips that I want to make about coming up with a plan of care number one is that This happens to me quite a bit and I don’t know maybe it’s my clinic type or setting or whatever but patients will come in Establishing care for the first time haven’t seen a doctor in years and years they’ve had a ten year old problem, but they come in with and They expect that I’m going to be able to fix it for them right then So that is not realistic So just this is just like a take home for you is that if there’s a chronic problem that’s going on for a very long time and it’s never had any workup or any treatment like That’s not realistic for and don’t put that pressure on yourself to try to fix it in that visit and also just setting up those Expectations for that patient of like you know what this is been going on for a long time I want to help you with this problem I don’t know if I’m gonna be able to fix it today, but here are the steps that we’re gonna take You know and here’s kind of like what to expect This comes from your algorithm. You don’t necessarily have to know this by experience once you get more experience You’ll be able to see that but I definitely like to prepare patients of like, you know Going back to the kid with like this strep, er, the sore throat I’m like, my approach is that you know, most likely you have a bacterial throat infection there’s a possibility it could be something else and depending on how nervous they seem or how a health literate they are in terms of like their understanding about health things I don’t want to overwhelm them but sometimes I’ll prepare them of like Oh You might have mono, you might have this, so that they know like please come back in the next week It may be this and we’ll kind of do this. So same thing with those ten year chronic problems Like do your best to come up with a plan based on that algorithm based on the most likely pertinent positive and negatives? Most like a diagnosis based on the pertinent positives and negatives and then just take it, you know from there the second real world thing I want to say is that– it commonly happens with the kinds of patients that will come in with a Ten-year problem after not seeing a doctor for ten years– is that they will have seventeen problems that they want you to fix today and You know what? They do want those problems addressed and I want to address those problems for them, but that is just not realistic, And it’s not realistic for a number of reasons. So number one So if somebody comes in with five problems, they want all those five problem solved, right, but they don’t– patients Don’t typically understand the workup and the treatment that is involved in in Taking care of those problems and a lot of the times especially when I was brand new I would do this all the time and I’d be like, okay, we’re gonna say needed three specialists. We’re gonna take these medications like Don’t do that [laughs] I mean you can it makes a patient’s where I say like I’m gonna overwhelm you if we address all of these things at once and they’re like no no, no, I just want to it So that’s really a discussion but like it’s gonna like number one it’s not really good for them because you’re not actually helping solve those five problems because they’re gonna get Overwhelmed and they’re not necessarily gonna be able to handle them all and number two It’s it’s just not realistic for yourself because like– I’m a super sucker and I try to do that for them, but like also It doesn’t benefit them but it doesn’t benefit me as a clinician and doesn’t necessarily benefit you as a clinician and that’s not selfish because that is helping To take really good care of not only your patients but yourself and if you don’t take good care of yourself then You can’t be an NP and then you’re not helping anybody, right? You’re not helping yourself, you know, your patients so it’s okay to protect yourself So what I say to patients is you know what you have five problems I want to make sure that we’re really addressing them thoroughly We’re not missing anything and that you’re not gonna get overwhelmed And neither of us is gonna get overwhelmed and that’s gonna actually solve the problems for you So what is the most important thing that you want to fix today? And you know patients don’t always necessarily appreciate Acuity, so somebody might be fluid-overloaded and be an active heart failure and they probably need some lasix or treatment like that So they’re sort of breath But then they also have toe pain and like they might decide that the toe pain is more bothersome than the shortness of breath but like, you have permission to triage that yourself and decide you know what I’m gonna deal with the shortness of breath and the toe pain or you know, Taking it from there. So I’d love to hear from you Are there any strategies that I mentioned that you’re using or steps that you’re using? Or is there something that you’re not–that you’re doing that’s separate from that? That’s working really well for you? I’d love to hear it because I learn from you but also the other nurse practitioners that watch these videos also Take a lot out of that. So so definitely me a comment below Did you like this video? If so hit like and subscribe– and share with your NP friends so that we can reach as many new grads as Possible to help ease their transition to practice as well. And so I mentioned in this video Don’t mean to be a broken record But the Ultimate Resource Guide is free available to you and it’s my favorite resources that I use every day So just head on over to Real World NP .com Sign up for the email list. You’ll get it straight to your inbox You’ll also get the weekly emails for me and you’ll get patient– more tips, patient stories and other bonus content That I just don’t share anywhere else– YouTube, Instagram, Facebook, website– nowhere else So sign on up– and I hear I hear that they’re pretty awesome. Thank you so much for watching Hang in there and I’ll see you next time

1 Comment

  • Reply NurseJane91 September 11, 2019 at 6:55 pm

    Such good tips I’m close to graduating with my AGNP! I’m hoping to ease the transition with all of the tips I come across.

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