Clinical Tips for New NPs

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Tips to help new NPs provide exceptional patient care

I was inspired to write this series to serve as a guide for student and new nurse practitioners. I remember being faced with so many things to consider during the last year of my family nurse practitioner program and my first year after graduation, and wishing I had someone to guide me through that transitional time. Now that I have worked as an NP in a few different specialties, I have compiled information that I feel would benefit new NPs. I love teaching and using knowledge I’ve acquired to help others. It is my hope that this article can provide navigation for student and new NPs.

In follow-up to the second article, “Basics for New NP Practice,” Part 3 offers student and new NPs clinical tips to help them provide exceptional patient care.

Clinical Tip #1: Warming Metal Speculums for Gynecologic Exams
While working in the family planning clinic at a reproductive health facility, I learned this tip. In the top drawer of your exam table, layer a dry heating pad on the low setting, blue pad, and the metal speculums. This warms the metal speculums, making them more comfortable for female patients. Prior to inserting the speculum and after informing them what you’ll be doing, test it on their inner thigh to make sure it’s not too warm for them. You can also store your lubricant jelly in its original container in that drawer as well. Not only is the speculum insertion a more comfortable process for them with a warmed speculum, but the bimanual portion of the exam is also better tolerated with warmed lubricant than cold.

Clinical Tip #2: Prepping Patients for Ease with Fingerstick Blood Draws
I found this helpful for making cholesterol, blood glucose, and mono fingersticks easier and less uncomfortable for patients. Have patients wash their hands in warm water, dry thoroughly, and then rub hands together vigorously before performing a fingerstick. The warm water combined with rubbing the hands together increases circulation to the fingertips making the fingersticks easier, allowing you to obtain the sample faster and often results in less milking of the fingers, therefore making it more comfortable for the patients.

Clinical Tip #3: Other Uses for Hydrogen Peroxide and Alcohol in the Clinics
A spot of blood on fabric blinds can be removed with hydrogen peroxide on a cotton ball. The following use is especially helpful in working with pediatric patients. One way to get crayon off wallpaper or the wall is to use an alcohol wipe. It comes off easily, especially frustrating if you’ve exhausted other clinic cleaning products!

Clinical Tip #4: Labeling Bandages
It may be helpful for practitioners (and patients may find it reassuring) to write the name of the vaccine/immunization on the corresponding bandage. This way if a patient were to have a localized reaction to one of them, a healthcare provider might be able to discern which vaccine/immunization it was in response to. For example, if more than one vaccine/immunization were given in the same arm (per Centers for Disease Control and Prevention (CDC) guidelines this is acceptable providing they are separated by at least an inch apart1) the close proximity of the vaccines/immunizations may pose a challenge; however, labeling the bandages might help and any tips that could potentially increase safety in practice are worth considering.

Clinical Tip #5: Convenient Pocket References
One thing I found helpful is keeping laminated cards in your pocket as quick, handy resources you can refer to in an instant. For example, working in family practice, I have found it helpful to keep a reference card with vital sign ranges (specifically pulse, respiratory rate, blood pressure) for pediatric, adolescent and adult groups and a reference card with the  immunization schedule (one card, pediatric schedule on one side, adult schedule on the other). If you are a FNP that works in a specific specialty, you may want to tailor the references specific to that specialty. For example, when I was working as a FNP in reproductive health, I kept a pocket reference of the different sexually transmitted diseases (STDs) and their corresponding recommended treatment regimens and another that listed the oral contraceptives with their generic equivalents. These little pocket references are not only helpful but also timesaving.

Clinical Tip #6: Using Tests According to Instructions for Assured Accuracy of Results
When I worked in urgent/retail health, a fellow employee saw a patient with symptoms of influenza and cultured the patient’s pulmonary sputum in addition to nasal secretions for a test that instructs culturing of nasal secretions only. The nasal specimen was negative while the pulmonary sputum specimen was positive; however, this can interfere with the accuracy of the result. When one uses a test not in accordance with the instructions, the validity/accuracy of results using that other method cannot be guaranteed and performing the test in that way is considered an “off-label” use.

The CDC website and public health experts are a great resource for providing assistance on such matters. For example, the CDC’s Influenza Symptoms and the Role of Laboratory Diagnostics website (which includes a link to an Influenza Diagnostic Table) explains acceptable specimens/testing technique for the different influenza tests. The CDC’s Rapid Diagnostic Testing for Influenza: Information for Health Care Professionals site also references the aforementioned table and explains that in order to minimize false results (i.e. false positives), it is imperative to follow the manufacturer’s instructions including handling of specimens. This is a helpful tip that could be applied across the board.

Clinical Tip #7: Knowing Your Over-The-Counter (OTC) Alternatives
For patients with certain cardiac conditions or uncontrolled hypertension who are seeking congestion relief but have been advised to avoid OTC decongestants, or for pregnant patients seeking congestion relief and an alternative to OTC decongestants, consider recommending an OTC nasal flush, e.g. SinuCleanse NetiPot, which is a nasal saline irrigation system/nasal-sinus wash that is a natural way to relieve congestion and sinus symptoms. Such products are indicated for a variety of conditions including but not limited to sinusitis, colds, flu, allergic rhinitis, and hormonal rhinitis.3 Saline nasal irrigation has proven to be effective in chronic rhinosinusitis and is recommended by different otolaryngologic societies.2

When you diagnose patients with viral conjunctivitis, this can be difficult because unlike bacterial conjunctivitis, it is not treated with antibiotic drops and treatment is usually limited to supportive care such as cool compresses. For such patients, consider recommending OTC Similasan’s Homeopathic Irritated Eye Relief (also called Pinkeye Relief), which is actually indicated for viral and environmental conjunctivitis.4 It works by stimulating the eye’s natural ability to relieve redness, watery discharge, and burning associated with viral and allergic conjunctivitis.5

For patients you diagnose with urinary tract infections (UTIs), rather than prescribing phenazopyridine hydrochloride (Pyridium) for immediate relief of UTI symptoms in addition to an antibiotic for the infection, consider advising OTC urinary analgesic tablets aka urinary pain relief tablets, which are the same medication as phenazopyridine hydrochloride, but available OTC and often cheaper. According to the Mayo Clinic,6 such urinary analgesics numb the bladder and urethra to relieve burning while urinating.

Clinical Tip #8: Quantify, Quantify, Quantify
You may have had this drilled into you during your nursing education, but it’s important and worth repeating. One of the electronic medical record (EMR) systems I used in a previous place of employment included a smoking assessment in the subjective portion of the EMR with selection choices “never smoked,” “previous smoker,” and “current smoker,” and no opportunity for notation. I found it helpful to make a note in the comment box at the conclusion of the subjective portion to quantify. For example, if a patient stated they were a current smoker, I would note how much they smoke and for how long (i.e. 2 ppd X 10 yrs.) or if a patient stated they were a previous smoker, I would note how long ago they quit or quit date. This information is important to note for following such a patient. For example, if a patient is a current smoker and quantity and duration are assessed at each visit, it allows the practitioner to follow them, tracking any progress they may be making to cut back or quit smoking.

Clinical Tip #9: Cholesterol Measurements
When I worked in urgent/retail health, we performed cholesterol screenings using the CardioChek machine. Sometimes, if a measurement was too high, it would not yield an accurate calculation. In this instance, I found it helpful to keep the following equation handy, in the event the measurement needed to be manually performed: LDL = total cholesterol- HDL- (triglycerides/5).7

Clinical Tip #10: Patient Education Take Home Messages
Primary care has its common conditions that present frequently. As quick as these are to diagnose and treat, we can’t forget the necessary education that might take us an extra minute or two, but is essential and worthwhile. With both strep pharyngitis and bacterial conjunctivitis for example, it is very important to inform patients that they are considered contagious until after they’ve been on the antibiotic for at least 24 hrs. (be it oral therapy for strep pharyngitis or topical therapy for bacterial conjunctivitis) and therefore not to return to daycare, school, or work until after they have been on the antibiotic for at least 24 hrs.8,9 For patients diagnosed with strep pharyngitis, it’s also important to advise them to change their toothbrush after they’ve been on the antibiotic for 48 hrs.8 I usually explain the rationale to patients in this way, “it is advised you change your toothbrush after having been on the antibiotic for 48 hours since we know that the strep bacteria can be harbored on your toothbrush, which can lead to reinfection.”

For patients diagnosed with bacterial conjunctivitis that wear contact lenses, it’s important to advise them to use eyeglasses if possible during the duration of the infection and then use a new pair of contacts, or at least thoroughly disinfect their current pair, once antibiotic drops are finished and the infection has resolved.9 It’s also important to advise female patients diagnosed with bacterial conjunctivitis to throw out old eye makeup since it can be contaminated and use new makeup when antibiotic drops are finished and infection has resolved. I also take this time to advise them not to share makeup and to be cautious with samples at makeup counters.9

Often times, these are not things our patients think of if we don’t tell them and can make the difference of whether or not they are reinfected. For patients diagnosed with UTIs, it is important to advise plenty of fluids, especially water and cranberry juice. Cranberry is commonly used for prevention and treatment of UTIs.10 For those patients who do not like the tart taste of cranberry juice, cranberry tablets are a nice alternative which can be found OTC in most pharmacies either in the supplement section or feminine care section. The American Congress of Obstetricians and Gynecologists states that unsweetened cranberry juice and cranberry pills may decrease the risk of getting a UTI.11 Other important education for patients diagnosed with UTIs includes advising them to avoid holding urine, rather to empty bladder when and as often as needed, and advising female patients to urinate after intercourse. Since some women do experience frequent UTIs related to intercourse, taking the time to give this preventive education can make the difference of whether or not recurrences are as frequent.

Clinical Tip #11: Easy Clean Up of Urine Specimen Containers
When working in the urgent/retail health setting, we kept a container of kitty litter under the sink. After we were done running a pregnancy test or performing a urine dipstick to check for a UTI, we would add kitty litter to the specimen container which would absorb the urine, and then we would secure the top and dispose. This eliminated the need to pour urine down a sink (which worked well because the clinic rooms only had one sink, not a separate clean and dirty sink). Also, in the event of exposure during trash disposal, should the top of the container come loose or off, rather than an exposure to bodily fluid, the sample has solidified due to the kitty litter.

Clinical Tip #12: Decoration Distractions
In an effort to help make female patients in a family planning clinic feel more comfortable and relaxed for their gynecologic exams, posters were placed on the ceiling directly above the exam table for them to look at, to distract them from focusing on their exam being conducted. Also a two-fold reason was education and awareness. For example, the poster may have a message about safe sex, encouraging condom use, the importance of human immunodeficiency virus (HIV) testing and knowing your status, the human papilloma virus (HPV) vaccine, etc. Another way of making the most of those teachable moments!

References

  1. Centers for Disease Control and Prevention. Vaccine administration. http://www.cdc.gov/vaccines/recs/vac-admin/default.htm
  2. Hildenbrand T, et al. Nasal douching in acute rhinosinusitis. Laryngorhinootologie, 2011;90(6).346-351.
  3. SinuCleanse. http://www.sinucleanse.com/
  4. Similasan. http://www.similasanusa.com/
  5. Walgreens pharmacy. Pharmacist frequently asked questions: Are there any over-the-counter products that get rid of pinkeye?http://www.walgreens.com/topic/faqhome/questionandanswer.jsp?questionTierId=700024&faqId=1300066
  6. MayoClinic. Urinary tract infection: Treatments and drugs.http://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/basics/treatment/con-20037892
  7. MDCalc. LDL calculated.http://www.mdcalc.com/ldl-calculated/
  8. MedlinePlus. Strep throat.http://www.nlm.nih.gov/medlineplus/ency/article/000639.htm
  9. KidsHealth. Pinkeye (conjunctivitis).http://kidshealth.org/teen/infections/common/conjunctivitis.html
  10. MedlinePlus. Cranberry.http://www.nlm.nih.gov/medlineplus/druginfo/natural/958.html
  11. American Congress of Obstetricians and Gynecologists. Frequently asked questions: Urinary tract infections.http://www.acog.org/~/media/For%20Patients/faq050.pdf?dmc=1&ts=20140609T2231151511
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About Author

Jenni Hoffman, DNP, FNP-C, CLNC

Jenni L. Hoffman is an assistant professor at Eastern Michigan University School of Nursing and a Nurse Practitioner with the Washtenaw County Department of Public Health.

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