The Cranial Nerve Assessment for Nurses

The Cranial Nerve Assessment for Nurses

The cranial nerve assessment is an important part of the neurologic exam, as cranial nerves can often correlate with serious neurologic pathology. This is important for nurses, nurse practitioners, and other medical professionals to know how to test cranial nerves and what cranial nerve assessment abnormalities may indicate. This becomes especially important when evaluating potential new strokes.

In school, cranial nerves tend to be something you memorize and then forget the day after the test. But they are important in testing a patient’s neurologic status, as an abnormality in a cranial nerve can indicate a central lesion (stroke, tumor, bleed, etc).

Every nurse should at the least know how to do a basic cranial nerve assessment, specifically the visual acuity and pupillary light reflex. When evaluating a stroke, The NIH scale is a method to evaluate the severity of a stroke. This scale walks you through evaluating many of the cranial nerves, but not all of them. If you want to feel confident when you chart “Cranial nerves II-XII grossly intact”, then keep reading!

1. The Olfactory Nerve (CNI)

The olfactory nerve is responsible for the sense of smell. Although rarely tested in practice, alterations in smell can be caused by serious intracranial pathology (brain tumors, strokes, TBI), neurodegenerative diseases like Alzheimer’s, Parkinson’s, or MS, or benign and transient causes such as the common cold.

If both branches of the olfactory nerve are damaged, this can lead to permanent anosmia (loss of smell) and can lead to food tasting bland and decreased appetite. In most individuals, the sense of smell decreases over time, with up to 75% of individuals older than 80 have some degree of anosmia.

 How to test the Olfactory Nerve

The olfactory nerve is almost never tested within an acute care setting such as in the hospital. However, this is sometimes tested in outpatient neurology offices. To test the olfactory nerve, blindfold the patient and have them smell and identify common scents such as vanilla, cinnamon, coffee, or peppermint while covering up one nostril at a time. Do not use ammonia or alcohol as these can trigger intranasal trigeminal nerve receptors and bypass the olfactory nerve.

2. The Optic Nerve (CNII)

The optic nerve is the second of the cranial nerves and is responsible for vision. This nerve transmits signals perceived in the retina and cones of the retina to the occipital lobe. This is commonly tested within the clinical setting and for a variety of presentations.

Partial or complete loss of vision can be caused by conditions such as:

  • Diabetes
  • Intracranial pathology (ischemia, stroke, tumors)
  • Inflammation or infection of the eye
  • Toxicity

How to test the Optic Nerve

When testing the optic nerve, you need to examine the visual fields, the visual acuity, and the pupillary light reflex. All three are an important part of the cranial nerve assessment, although the pupillary light reflex involves cranial nerve 3 as well.

Testing the Visual Fields (II)

If the patient loses part of their vision on one side, it is termed partial hemianopia, and if they lose complete vision on one side it is complete hemianopia. There are a few different ways to test visual fields, but here is an easy way. Stand one arm length away from the patient and ask them to cover up one eye or do it for them if they are unable. Close your own eye on the same side. Now hold up numbers with your fingers at each of the four corners of their vision. Once satisfied, test the other eye.

Testing the Visual Acuity (II)

Nurses often assess visual acuity, and most emergency departments will have a Snellen eye chart to use. The distance the patient stands depends on the visual acuity chart (it should say). If you do not have easy access to this, there is an app you can get on your phone which is super helpful!

Have the patient stand the appropriate distance away and have them cover up one eye. Do not have them forcibly close the eye as this can somewhat inhibit their ability to see out of their open eye. Ask the patient to read the 20/20 line on the chart. On a standard Snellen eye chart, this would be 20 feet away. If the patient gets more than half wrong, move onto the line above. Stop once the patient gets over 50% right. Mark this down and test the other eye. If they wear glasses – have them wear their glasses for this as well!

Pupillary Light Reflex (II, III)

The pupillary light reflex tests both cranial nerves II and III. First, inspect both pupils and make sure they are equal in size and shape. Then dim the lights if possible and shine a penlight directly into the right eye. Both pupils should constrict and maintain symmetry. Note if they are brisk or sluggish and if they are symmetric. Remove the light source and watch both eyes dilate equally as well. Do the same for the left eye.

3. The Oculomotor Nerve (CNIII)

The oculomotor nerve controls the majority of the extraocular muscles. It is primarily responsible for eye movement, eyelid movement, and pupillary constriction. If there is any oculomotor nerve impairment, there will be a pupillary dilation, ptosis (drooping eyelid), and outward deviation of the eye – termed abduction. When a patient has diplopia (double vision), it is often due to a unilateral lesion on this cranial nerve. In most cases, third nerve palsy resolves over weeks to months.

Causes of oculomotor nerve palsy include:

  • Intracranial aneurysm
  • Microvascular ischemia (in diabetics especially)
  • Trauma: Severe blows to head with skull fracture

Testing Extraocular Muscles (III, IV, VI)

To test the oculomotor nerve, you need to assess the EOMs. Testing the EOMs also tests cranial nerves IV and VI, as all three nerves are responsible for eye movement.

Hold your finger or a pen 2 feet in front of the patient’s eyes midline and have the patient focus on it with both eyes. Ask the patient to follow your finger or pen with only their eyes, moving the pen to the right, back to the midline, and then to the left and back again. Do this again for up and down. Lastly, do this again to the down-left diagonal angle, and then the down-right diagonal angle. You should have tested a total of 6 different directions – termed the “6 cardinal directions”.

Eye movement should be symmetric, smooth, and moving in all directions. At each extremity of vision, you should be observing excessive nystagmus. Nystagmus is repetitive uncontrolled eye movement.

Conjugate nerve palsy is when both eyes are unable to look in a specific direction during your testing. This most commonly occurs in the horizontal directions. This is usually due to a stroke within or near the brain stem.

The pupillary light reflex listed above is also used to assess the oculomotor nerve.

4. CN IV: The Trochlear Nerve

The fourth cranial nerve, the trochlear nerve, innervates the superior oblique muscle of the eyes. This means it controls the downward movement of the eyeball and prevents it from rolling upward. When there is a fourth nerve palsy, patients will often complain of vertical diplopia and/or tilting of objects. This may be most noticeable when in a downward gaze such as when going down the stairs. They may also have a head tilt, as the visual changes improve with tilting of the head. On exam, the eye will with deviated upward and rotated outward.

Testing the trochlear nerve involves evaluating the patient’s extra-ocular movements as described above.

5. CN V: The Trigeminal Nerve

The Trigeminal nerve is the 5th cranial nerve and responsible for facial sensation, as well as moving the muscles involved with biting and chewing. This has three branches including the ophthalmic V1, maxillary V2, and Mandibular V3. Compression of this nerve root can cause trigeminal neuralgia – a rare but painful condition.

How to test the Trigeminal Nerve

To test the trigeminal nerve, you are testing their facial sensation. Lightly touch both sides of the forehead and ask if they felt the same. Do this on the cheek, and then the chin. If the patient is uncooperative, you can test their corneal reflex. Do this by having the patient look right, then touch their left cornea with a whisp of cotton. They should blink. Do this on both sides.

6. CN VI: The Abducens Nerve

The sixth cranial nerve, the abducents nerve innervates the lateral rectus muscle of the eye. This means its responsible for outward movement of the eyes. Patients with dysfunction of this nerve will be unable to outwardly move their eyes. This causes horizontal diplopia, where the double images are side-by-side, which is worse at far distances.

This nerve is often the first nerve compressed when there is any increased intracranial pressure (ICP). However, more common causes include vascular disease (diabetes, hypertension, atherosclerosis) or trauma.

To test the abducents nerve, test the EOMs as described above.

7. CN VII: The Facial Nerve

Cranial nerve VII is the facial nerve, which controls the muscles of facial expression, as well as the sensation of taste of the front of the tongue. Facial nerve palsy can occur for various reasons, the most common being Bell’s palsy. Some other common causes include stroke, Lymes disease, trauma, or even diabetes.

How to test the Facial Nerve

To test the facial nerve, you must assess the patient’s facial expressions. Have the patient close their eyes tightly, then have them open their eyes. Ask them to frown, looking for symmetry in the forehead muscles. Have them smile and look for any drooping or asymmetry.

Clinical Tip: To differentiate Bell’s palsy from stroke, assess the patient’s use of their forehead muscles. Peripheral nerve lesions (such as with Bell’s palsy) cause paresis of the entire side of the face. Central lesions tend to only effect the lower portion of the face. This is not always the case though, so you must use clinical judgement. Bell’s palsy should have no other associated neuro deficits. Check out my Infographic for more information!

8. CN VIII: The Vestibulocochlear Nerve

The vestibulocochlear nerve, also called the auditory vestibular nerve, is responsible for hearing and balance. Vestibular neuritis is when the nerve becomes inflamed and can cause vertigo, dizziness, and balancing difficulties – most likely from a viral infection.

How to test the Vestibulocochlear Nerve

While not routinely tested within the hospital, the vestibulocochlear nerve involves testing both hearing and balance. Hearing is tested by holding your fingers a few inches away from their ears and rubbing them together. If they can hear, then that is a pass. Test their balance by assessing their gait while walking. The presence of nystagmus can also indicate vestibular dysfunction.

9. CN IX: The Glossopharyngeal Nerve

The glossopharyngeal nerve is partially responsible for the sensation of taste, pharyngeal sensation, as well as for the gag reflex. A damaged glossopharyngeal nerve can cause a loss of taste in part of the tongue and cause trouble swallowing.

How to test the Glossopharyngeal Nerve

Palatal Movement (IX, X)

Instead of doing the gag reflex which can be very uncomfortable for patients, you can instead assess palatal movement. Do this by having the patient yawn or say “ahh”, and observe their palate movement for symmetry. If this is abnormal, consider testing the gag reflex.

Gag Reflex (IX, X)

When performing the cranial nerve assessment, the easiest way to test the glossopharyngeal nerve is to test their gag reflex, however, this is usually not necessary in the clinical setting. Remember that approximately 20% of people will not have a gag reflex at baseline. Check both sides of the pharyngeal wall by gently poking the pharynx with a cotton swab.

Dysarthria (IX, X, XII)

There is no specific test for this but listen to the patient’s speech. Assess for any slurred speech or abnormality of the voice. Ask the patient or the family if it sounds different than normal.

10. CN X: The Vagus Nerve

The Vagus nerve innervates the hearts, lungs, and digestive tract, along with a few muscles. Most noticeably, it controls the heart rate, GI motility, sweating, and speech. It is also partially responsible for the gag reflex (along with cranial nerve IX).

Overstimulation of the vagal nerve can drop the heart rate and cause syncope, termed vasovagal syncope. Activities that stimulate the vagal nerve include bearing down, holding breath, carotid massage, or extreme fear or stress.

There are even implantable vagus nerve stimulators that can help slow down the firing of neurons within the brain and thus help manage seizures.

How to test the Vagus Nerve

The only real way to test the vagus nerve is via the gag reflex as described above.

11. CN XI: The Accessory Nerve

The accessory nerve innervates the sternocleidomastoid and trapezius muscles. This means it is responsible for tilting/rotating the head as well as shrugging the shoulders. This nerve can be damaged after neck surgery or blunt force trauma.

How to test the Accessory Nerve

To test the trapezius muscle, ask the patient to shrug both of their shoulders at the same time. Then apply some downward pressure with both hands and ask them to shrug both shoulders against the resistance.

To test the sternocleidomastoid, place a hand against their cheek and ask them to rotate their head against resistance in each direction. If you notice weakness, this indicates the opposite side is the weaker muscle.

12. CN XII: The Hypoglossal Nerve

The hypoglossal nerve controls most of the movement of the tongue. This means it is highly responsible for speech and swallowing. Damage to the hypoglossal nerve is rare, but if so are likely to be caused by tumors or gunshot wounds. Other causes include stroke or neurodegenerative disease.

How to test the Hypoglossal Nerve

To test the hypoglossal nerve, ask the patient to stick out their tongue. If the tongue deviates to one side, this indicates hypoglossal nerve dysfunction on the side of deviation. Then ask them to move their tongue from side to side rapidly. Additionally, listen for dysarthria when the patient is speaking as described above.

Cranial Nerve Assessment Cheat sheetCranial Nerve Assessment Cheat Sheet

How’s that for a refresher?  Although we may have forgotten some of the in’s and out’s of the cranial nerve assessment, this should serve as a reminder for how to examine cranial nerves. Hopefully, after reading this, you can feel more confident in your neurologic assessment!

If you need an easy cranial nerve assessment handout, you can download my handout here! This is the perfect cheat-sheet that you can refer to in practice when assessing cranial nerves!

References:

Gelb, D. (2019). The detailed neurologic examination in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults

Lee, A. G. (2019). Third cranial nerve (oculomotor nerve) palsy in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/third-cranial-nerve-oculomotor-nerve-palsy-in-adults

Lee, A. G. (2019). Fourth cranial nerve (trochlear nerve) palsy. In UpToDate. Retrieved from https://www.uptodate.com/contents/fourth-cranial-nerve-trochlear-nerve-palsy

Mullen, M. T. (2014). Differentiating Facial Weakness Caused by Bell’s Palsy vs. Acute Stroke. Journal of Emergency Medical Services39(5). Retrieved from https://www.jems.com/2014/05/07/differentiating-facial-weakness-caused-b

Oculomotor Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/oculomotor-nerve

Olfactory Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/olfactory-nerve

Rea, P. (2014). Clinical Anatomy of the Cranial Nerves. Cambridge, MA: Academic Press.

Trigeminal Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/trigeminal-nerve

AANP vs ANCC: Nurse Practitioner Certification

AANP vs ANCC: Nurse Practitioner Certification

When Nurse Practitioners graduate, they must take a national exam that certifies them to practice in their specific specialty. Once they have this board-certification and obtain their state licensure – they can legally practice as a Nurse Practitioner.

These exams can be likened to the NCLEX-RN that RNs have to take to become a  certified Registered Nurse. The only difference with nurse practitioner certification is that there are TWO to choose from, from two different certifying bodies – so you must choose between the AANP vs ANCC. But what exactly are they?

If you’d rather watch the full video, click the image below!

American Nurses Credentialing Center (ANCC)

The American Nurses Credentialing Center (ANCC) is an independent credentialing branch of the American Nurses Association (ANA) which certifies nurses to become advanced practiced registered Nurse (nurse practitioners!) This is the largest nurse credentialing organization in the U.S. and is not limited to Nurse Practitioners. They also certify nurses in informatics, professional development, case management, and various nursing specialties.

ANCC Exams

Regarding Nurse practitioner certification, the ANCC provides certification for the following specialties:

  • Family Nurse Practitioner (FNP-BC): 175 questions (150 graded)
  • Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP-BC): 150 questions (135 graded)
  • Adult-Gerontological Acute Care Nurse Practitioner (AGACNP-BC): 200 questions (175 graded)
  • Psychiatric-Mental Health Nurse Practitioner (PMHPNP): 175 questions (150 graded)
  • Pediatric Primary Care Nurse Practitioner (PPCNP-BC): 200 questions (175 graded)

The ANCC exams questions will have a majority of clinical assessment, diagnosis, and management, but will have about a 25% or more of non-clinical questions. This means questions on research, ethics, professional responsibility, leadership, the scope of practice, regulatory guidelines, etc.

Time allotted is generally about 4 hours – including time for check-in, instructions, and a practice session on the computer. If you fail an ANCC exam, you can retake the exam in 60 days, but you cannot test more than 3 times in 12 months.

Cost

The cost for the nurse practitioner certification exam through the ANCC is $395 for non-members of the ANA, and $295 for members.

ANCC Pass Rates (2018)

The following pass-rates for each ANCC exam are as follows:

  • FNP = 86.2%
  • AGACNP = 89.5%
  • AGPCNP = 79.0%
  • Peds = 85.7%
  • Psych = 88.5%

American Academy of Nurse Practitioners (AANP)

The American Academy of Nurse Practitioners (AANP) is a relatively new organization formed in 2013 for the nurse practitioner certification. Their certification board offers examinations for Nurse practitioners similar to the ANCC, however, there are significant differences between the AANP vs ANCC.

AANP Exams

The AANP currently only has the following three nurse practitioner certification exams:

  • Family Nurse Practitioner (FNP-C)
  • Adult-Gerontology Primary care Nurse Practitioner (A-GNP)
  • Emergency Nurse Practitioner (ENP)

Unlike the ANCC (and a major plus in my personal opinion) is the fact that the AANP exams are 100% clinical. This means it will focus on the assessment, diagnosis, plan, and evaluation of various clinical scenarios and patient cases. The only difference is that the Emergency Nurse Practitioner certification exam does have some non-clinical content, including a small percentage of professional, legal, and ethical practice questions.

All three exams have 150 questions, 135 of which actually count toward your grade.

Cost

The AANP exam costs $315 for non-members of the AANP, and $240 for members.

AANP Pass Rates (2018)

The 2018 pass-rates for the AANP nurse practitioner certification exams are as follows:

  • FNP = 85%
  • AGPCNP = 83%
  • ENP = 87%

AANP vs ANCC: What’s the difference?

Both the AANP and the ANCC exams are taken on the computer at a testing center. Every few years new editions of the tests are created, and multiple alternate versions exist. These exams differ from the NCLEX-RN in that they do not finish based on your score (i.e. it won’t shut off at 75 questions). You must complete the entire test.

The Number of Questions

The number of questions is going to differ depending on which exam you are taking. ANCC exams vary from 150-200 questions over 3-4 hours, and all AANP exams are 150 questions. Both tests will have 15-25 “pretest” questions – meaning they won’t count for your grade – they’re just testing the questions to see if they’re okay to add to future versions of tests.

The Question Style

The style of the test questions is another major difference. ANCC exams will have four different question formats: multiple-choice, multiple response questions, drag and drop, as well as “hot spot” questions. AANP is 100% multiple choice with 4 possible options (aka NO select all that apply!).

The Question Content

The content of the questions is also a major difference between the AANP vs ANCC. It’s going to vary depending on which exam you’re taking, but the ANCC exams tend to have a lot more “non-clinical” questions related to topics like nursing research, legal and ethical considerations, scope of practice, regulatory guidelines, etc. AANP is 100% clinical, so it is going to focus on assessment, diagnosis, treatment, and evaluation. As stated above, the ENP test is a bit different and does have some non-clinical questions.

The Difficulty

There have been some rumors that AANP is easier than the ANCC – although there really is no way to truly know. The pass-rates used to be lower for the ANCC so people just assumed it’s harder. However, now if you look at the most recent data for FNP (2018), the AANP actually had a lower pass rate (85% VS 86.2%). I think it’s going to depend on the individual which one is easier based on their preferred testing style and testing content. The only true way to know is to take both yourself which I do not recommend!

The cost

The cost is also slightly different. Non-members will end up paying $315 for the AANP vs ANCC paying $395, making AANP $80 cheaper. If you are members of the ANA, the ANCC will only be $295. On that same note, members of the AANP will pay only $240 for an AANP exam.

AANP vs ANCC: Factors to Consider?

Which exam you choose will depend on your specific professional goals as a future NP.

1. Which Specialty is your program in?

This one is great because all the work is done for you. In order to apply for certification, you have to have graduated or will be graduating from an accredited Nurse practitioner program in that specific specialty. So, if you’re program was FNP – you need to apply for FNP certification. Obvious right?

For certain specialties – this choice will be made for you because both the ANCC and the AANP have certification exams that the other does not.

If your program is for Acute care, Psych, or Peds – you must go through the ANCC.

If your program is an Emergency NP program   – you must go through the AANP.

Where the real choice lies is if you went to a Family Nurse Practitioner (FNP) program or an Adult Primary Care (AGPCNP) program. And if that’s the case, then the next question you’re going to want to ask yourself is what your specific testing preferences are. What do I mean? Keep reading!

2. What are your testing preferences?

The AANP vs ANCC has very different test styles and question content as stated above. If you’re someone like me who HATED research, ethics, leadership (insert more fluff classes here), then you are more likely to want to take the AANP. In fact, that’s the main reason that I chose to certify through the AANP! If you are really good at non-clinical questions like that – maybe you should take the ANCC!

Additionally, the AANP is 100% multiple choice with four possible answers. The ANCC exams are multiple-choice, but do include alternate questions including the dreaded multiple response questions, drag and drop, as well as “hot spot” questions.

3. Which facilities are you planning on applying to?

So nowadays most facilities and locations look at AANP vs ANCC certified NPs as pretty much the same. This is because both are nationally recognized and reimbursed by Medicare and Medicaid in any clinical setting in almost all states.

Think of this like DO vs MD – both are now considered equally great. So, most facilities don’t’ really care – they just want to see that you passed your boards.

However, rarely there are facilities that prefer ANCC candidates because it’s older, more established, and isn’t 100% clinical.

So if by the rare chance that the facility you want to work in only accepts ANCC – consider taking that exam instead. In general, magnet hospitals do NOT require ANCC over AANP.

4. What are your future career goals?

The last consideration is what are your future career goals? Do you plan on obtaining any post-master certifications? You totally can be certified in one specialty by the AANP and certified in the other by the ANCC – but this just might complicate things a bit. You’ll likely feel more comfortable with the certification process if you have already done it once. So, if you’re in an FNP program and want to one day become ENP certified – AANP might be the more logical choice for you. On the other hand, if you want to one day get your ACNP or PMHNP post-masters certifications, consider the ANCC!

Additionally, if you plan on getting into academics – some universities may prefer ANCC NPs. However, to teach at the nurse practitioner level, you will need to be pursuing or have obtained your doctorate degree anyway.

What did I choose?

I chose the AANP exam. What it came down to was the fact that I love clinical questions and really did not like all the other types of questions (research, ethics, etc). I also don’t like alternative question formats, so a normal multiple-choice exam sounded perfect to me. I didn’t foresee any problems with having my AANP nurse practitioner certification vs an ANCC certification, and I haven’t experienced any drawbacks. There is one local hospital system that prefers ANCCs, and they explicitly state so on their job applications. But – who wants to work there anyway.

If you are in NP school and about to graduate, I want you to check out my NP certification steps, where I walk you through the process of getting licensed, certified, and credentialed as an NP! Heads up – it can take longer than you think!

Nurse Practitioner vs Physician Assistant

Nurse Practitioner vs Physician Assistant

Advanced Practice Providers (APPs) are an integral part of the healthcare team. They both perform very similar jobs, oftentimes the same one! But what exactly is the difference between them? In this article, I am going to walk you through and compare the education and training, job role, physician collaboration, as well as the salary of both NPs and PAs.

If you’d rather watch the full video, click the image below!

Education and Training

Both Nurse practitioners (NPs) and Physician Assistants (PAs) are considered Advanced Practice Providers or APPs, and they both often work alongside physicians in many facilities and practice settings. This tends to lead to some confusion over what the difference actually is.

Please note that there are various alternative methods of obtaining your NP including direct-entry programs and RN-MSN bridge programs, but I will not be going over these within this article. Additionally, this article compares master’s prepared NPs vs master’s prepared PAs. Of course, there are many NPs who obtain their Doctorate of Nursing Practice (DNP), but that will not be talked about in this article.

Related content: “NP vs MD: Which one is better?”

Undergraduate Degree

PAs will first obtain an undergraduate bachelor’s degree in a whichever degree they desire, but they must complete their prerequisites for PA school. At the same time, a future NP will typically obtain their Bachelor’s of Science in Nursing (BSN). Both of these undergraduate degrees typically take about 4 years to complete, although some direct-entry PA programs complete the Bachelor’s degree portion in closer to 3 years.

During this part of their education, PA students won’t typically perform any formal clinical, but will often have to complete between 1000-4000 hours of direct patient healthcare experience which is required for PA school. This is usually experience being an EMT or paramedic, a patient care technician or Certified Nurses Assistant (CNA), or a medical scribe. BSN students, on the other hand, will complete between 800-1000 clinical hours on average within the hospital learning how to be a bedside nurse.

After Graduation

Upon graduation, PAs should have already applied and been admitted to a PA program to obtain their Master’s degree, and they will immediately move on to their graduate education. The NP, however, will pass their board certification once they graduate, the NCLEX-RN. They then begin working as a bedside nurse. There are some RNs who immediately go right into their NP studies, but most will work for as little as a year to as long as 20+ years before pursuing their master’s degree.

The PA/NP Programs

PAs  will complete a Master’s degree in any of the following, depending on their program:

  • Master of Physician Assistant Studies
  • Master of Health Science
  • Master of Medical Science (MMSc)

NPs will complete a Master of Science in Nursing (MSN). During their program, PAs are trained as generalists, so they can essentially work in any clinical setting so long as they have appropriate physician supervision. Instead, NPs must choose a specific patient population to focus on. When entering the program of their choice, the NP will have to choose one of the following patient populations:

  • Family (across the life-span)
  • Adults and Geriatrics (ages 13 and up)
    • Primary Care
    • Acute Care
  • Behavioral/Mental Health
  • Pediatrics (ages 0-18)

Program Structure:

Most PA programs last about 2 full-time years of study (24-26 months). The first half they’ll go through didactic material learning in-depth medical sciences. Think of this as the first half a medical school but compressed into only 1 year. In the last half, they’ll complete clinical clerkships in pediatrics, OBGYN, family practice, general surgery, and emergency medicine, totaling about 2,000 hours of clinical experience.

NP programs are structured differently and usually have Full-Time, Part-time, and online options. Most programs will start out with solely didactic material including advanced pathophysiology, advanced pharmacology, and advanced health assessment. You’ll then start clinicals but at the same time continue didactic material simultaneously. It’s common to have to complete 16 hours per week fo the semester in clinical, so two 8-hour days each week.

Where you do your clinicals is going to depend on the program specialty, so FNPs will do rotations in primary care clinics, women’s health clinics, and pediatric clinics, whereas Acute care NPs would do most of their rotations within the hospital in the ICU. Some programs offer optional specialty rotations, where you can get experience in something other than your “typical” locations (like the ER for FNPs). NPs will complete an estimated 600-800 hours of clinical by graduation.

Licensure

Once they graduate from their APP programs, PAs must pass the PANCE (Physician Assistant National Certifying Examination) in order to become a certified PA. NPs will have to pass their board certification exam in their specific specialty (either through the AANP or the ANCC). They both then apply for state licensure and can start practicing as APPs once credentialed

Related content: “Nurse Practitioner: Steps after graduation”

Job Role

The actual job role of an NP and a PA regarding what they actually do is VERY similar if not the same at almost any location and specialty.

Both PAs and NPs:

  • Obtain health histories from patients
  • Perform a physical assessment
  • Order diagnostic tests and interpret them
  • Prescribe treatments such as medications and therapies
  • Perform bedside procedures
  • Consult appropriate specialists

They both work in pretty much every specialty including:

  • Outpatient primary care
  • Outpatient and inpatient specialty offices
  • Inpatient hospitalists or ICU
  • Emergency Department or Urgent Care Clinics
  • Home Health / Hospice
  • Surgery
  • More!

Regarding surgery, NPs can become a first-assist with a surgeon but its much less common – usually they’ll do admissions and discharges for the surgical team instead of actually scrubbing in. PAs are more likely to scrub in and assist with surgery. NPs generally do not receive any surgical rotations throughout their program, so this just makes sense.

Collaboration/Supervision

APPs often work in close collaboration with physicians – but this is where the main difference lies between the two.

NPs have full practice authority (FPA) in 23 states and counting. What this means is that State practice and licensure laws permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.

This means there is no required supervision or collaboration with a supervising physician. They practice medicine under their own license without any oversight. However, just because an NP might practice in an FPA state, this does not mean that they do not consult or collaborate with other experienced NPs and physicians when appropriate – it just means they have the legal authority not to.

NPs who do not live in an FPA state will require varying degrees of physician collaboration depending on their state and practice setting. This degree of physician collaboration is explicitly stated in a collaborative agreement, which outlines joint practice protocols, documentation review/oversight, and prescriptive authority. In practice, this often just involves occasional chart reviews and availability for consultation via electronic consultation via text or phone call. This doesn’t require an on-site physician.

Alternatively, PAs are always required to work under the direction and supervision of a physician or a group of Physicians. However, State-level laws influence more specific aspects of supervision including prescriptive authority, prescription co-signatures, collaborative agreements, and other various aspects of scope of practice.

So what does this mean?

Basically, PAs have more required oversight by physicians, but this does not mean that the physician is looking over their shoulder. Typically, this may involve the PA consulting the doctor with medical management of a complicated case, and the physician co-signing their charts and prescriptions for controlled substances. But this will look different in every State and practice setting, and the physician often won’t be required to even be on-site – just usually needs to be reachable.

All states will vary for both NPs and PAs in terms of who is legally able to sign death certificates, POLST forms, and/or order physical therapy.

As a general rule, the NP career offers more opportunity for autonomy. This is especially useful if you plan on opening your own practice or clinic, especially in an FPA state. PAs, at this time, are more limited in their ability to perform medicine autonomously.

Both NPs and PAs are a great part of the healthcare team, and both are very competent and able to take care of their patients within their respective scope of practices.

Salary

When looking at salary – both NPs and PAs make similar salaries and many locations and facilities will pay their counterparts the same. However, when looking at national data – NPs make on average $117,292, and PAs make $107,179 (Glassdoor). Keep in mind that this is national data. The fact that some NPs have the autonomy to open up their own practices typically means higher revenue, which will skew the national NP salary upwards.

Related content:

And that is basically the difference between PAs and NPs. They are both very different paths, but essentially perform the same job role and have similar career outlooks. Some physicians and hospitals will prefer one type of APP over the other, and I’ve seen this go both ways. However, most places of employment will recognize the value of both an NP and a PA as integral members of the healthcare team.

 

NP vs PA

Calling the Doctor – Giving Nurse to Provider report

Calling the Doctor – Giving Nurse to Provider report

This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information

When I first started working as a bedside RN, one of the aspects of the job that gave me a deep sense of anxiety was having to call the doctor on a patient. Sure – some of them were super nice – but many of them were impatient and rude. Not giving the correct phone report in a format that the physician or Advanced Practice Provider (APP) is looking for can create tension and miscommunication. If you utilize my technique for giving phone report to the physician – the patient’s situation will be more effectively communicated and the encounter will go much smoother.

In this article, I am going to share with you all an effective method for giving a quick report to the physician or APP when you call them in the inpatient setting! I am uniquely positioned to help with this because I work as a Nurse Practitioner in the hospital and receive 20-30 calls per night from floor nurses. I have noticed many improvements that can be made to improve communication – so keep reading!

Step 1: Introduce yourself and the patient

“Hi, My name is Michelle and I’m calling from 1G. I’m the nurse taking care of Anita Lopez in 230-2. Are you familiar with her?”

First you need to introduce who you are, where you’re calling from, and who you’re calling about. I can’t tell you how many times the nurse has called me and launched into a full explanation about the patient and then I have to ask “Who is the patient!?” Oftentimes the inpatient Provider is at the computer and can look up the patient’s chart while the nurse is talking.

Sometimes over the phone it is difficult to understand last names – especially if accents are involved. When you say the patient’s name, it helps if you say “Anita Lopez, that’s L-O-P-E-Z”. Spell out the last name because oftentimes we have censuses pulled up from each floor or hospital which are ordered alphabetically. We usually do not need the spelling of the first name.

It also can be helpfult to include where they are located – their unit and room number. Additionally – the Provider you are calling may only cover certain attending physicians (as is the case at my job). If this is so – give the attending physician as well.

The next step is to ask if they are familiar with the patient. If I just admitted the patient – I don’t need a full explanation of why they’re here and what their medical history is. However, many specialists or Providers who are on call may not be very familiar with the patient yet. It always helps to ask and most Providers won’t give you an issue by asking.

Step 2: Brief Medical History

“She’s a 78 year old female who came in on 11/28 for a COPD exacerbation. She has a PMHx of COPD, Smoking, Hypertension, Hyperlipidemia, and afib which she’s on Coumadin for”

In the inpatient setting – I always want to know why the patient was admitted. This gives some context to the patient’s situation. If a patient who came in for COPD exacerbation is complaining of a headache – that typically deems less investigation than a patient who came in for a TIA or a mechanical fall and is now having a headache.

Additionally, a brief overview of their medical history should be given with emphasis on important/related diseases. Hit the following:

  • Cardiac: HTN, CAD (any stents or CABG?), Afib (anticoagulants?), CHF
  • Pulmonary: COPD, asthma, Lung cancer
  • Renal: AKI, CKD, ESRD (on dialysis?)
  • Vascular: DVT/PE, PAD/PVD

You usually don’t need to go into any details regarding surgical history unless it is directly relevant to this admission in some way.

Step 3: Why You’re Calling (SITUATION)

“The patient is complaining of increased SOB”

This is pretty simple. Why are you calling the Provider in the first place? Usually this is due to :

  • A new complaint: Chest pain, SOB, Headache
  • A medication need: sleeping medication, breathing tx, pain medicine
  • A change in the patient’s status: Respiratory distress, Unresponsive, confusion
  • A critical lab value : elevated troponin, elevated lactic, positive blood cultures

No matter why you’re calling – simply state it and then jump into the following step – the background of the situation.

Step 4: Situation Background

“They are ordered duonebs q6h but has nothing ordered PRN”

By this point you already given the important information such as who you are, who the patient is, where they are, why they were admitted, and why you’re calling. Now you can get to the heart of the call and give context to the situation at hand.

In this instance, the patient is SOB and has COPD. Are they ordered breathing treatments and how often? No matter why you’re calling, it helps to ask these questions:

  • Has this happened before and what was done? Did it help?
  • Are they currently on any medication for the situation?
  • What trends have been occurring (i.e. if you’re calling for high BP, how have their BPs been?)

Investigating the background of the situation can really help communicate the correct need to the Provider.

Step 5: Assessment

“The patient’s RR is 24 rpm and SPO2 is 90% on 2L NC. They’re breathing is non-labored, lung sounds show expiratory wheezes throughout”

As the nurse, you are responsible for assessing the patient first when there is a change in their status. This doesn’t mean you need to do an entire nursing assessment and report that, but get their vital signs and a do a quick physical assessment of the systems involved (I.e. If you’re calling for SOB – tell me how they are breathing and what their lungs sound like).

Please make sure you get an UPDATED set of vital signs whenever there is a change in patient status. Their vital signs from the 3-4 hours ago are not helpful to the current situation (depending on why you’re calling). That’s just good practice.

Step 6: Recommendations

“Can you please add albuterol PRN for inbetween scheduled duonebs”

Nurses are the eyes, ears, and hands of health care. They are on the front lines, are well-educated, and usually have great recommendations to help their patient. Maybe you know just what the patient needs to feel better.

Another important recommendation is asking if the Provider can evaluate the patient in-person. Sometimes it is difficult to convey your uneasiness about how a patient looks – even if their “numbers” look fine. Asking the Provider to personally evaluate the patient (if needed and indicated) is a great way to ensure the patient is in good hands.

Related Content: Tips for New Nurse Practitioners

– – – – – –

So Yes, it is SBAR, but with some important introductory steps beforehand. But what if you’re a Provider and need to know how to call consults to other Providers? I’m going to let you in on a secret – these steps are exactly what I do when I call a Provider for a consult as an NP. There really is no difference between a good nurse-to-provider report or a provider-to-provider SBAR.

As long as all the relevant information is conveyed in a concise and organized manner, you will be sure to impress the Providers you are calling, and ensure that proper communication is maintained – giving your patient the best possible care.

Tips for New Nurse Practitioners

Tips for New Nurse Practitioners

This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information

While I’m no expert NP, I do know what its like to be a new one! After all – that was just a little over a year ago! Being so fresh in my mind – I have some valuable tips to share with new NPs or NPs to be. No matter what setting you start in, utilize the resources you have available to you, work your butt off, and constantly be open to learning – and you will succeed! But to help you on your journey – here are 6 of my best tips for clinical practice!

1. Use UpToDate Religiously

If you haven’t heard of UpToDate – I don’t know how you made it through NP school! This medical reference database is the GOLD STANDARD of medical information for Providers. While I’m working, I often use this to quickly reference drug dosing information and renal dosing considerations. On the spot, the algorithms are SUPER useful. You can just scroll down to the bottom, check out the algorithm section, and viola – suddenly you know just what to do for your patient with hyponatremia of unknown etiology. No but really – there is SO much useful information. If you have a bit more time on your hands – you can read through articles more in-depth related to literally whatever medical topic that is relevant to your clinical practice. Keep a list throughout the day of symptoms and diagnosis that you don’t feel 100% comfortable with, and make a habit of reading up on those topics on UpToDate at the end of the day.

Unfortunately, UpToDate is expensive, but most hospitals provide free access for it’s providers. If you create an account, you just have to login once every 3 months on the hospital’s network to maintain access – and you can download the easy-to-use app for your smartphone.

There are other reference apps out there – but UpToDate is by far my favorite and the gold standard. Check out my top 5 medical reference apps for more information!

2. Templates, Templates, Templates

When you’re a new NP – you are going to be overwhelmed – especially in a new hospital or office environment. You are going to forget to ask basic questions to the patients, and you are going to feel dumb plenty of times. You likely won’t have the most confidence when conducting you’re history and physical. That’s why templates are SUPER important in being your back-up. Find templates such as History/Physical or SOAP note templates, and use them with every patient. This will ensure that you don’t forget to ask about surgical history, family history, smoking status, even something as easy as allergies. If you can’t find a template that works for you – make one yourself! Get a system down, write down information in the same place when you’re doing your chart reviews, and this will help you know where to always find the information you need on your patient – especially in high-stress situations.

Since working as an inpatient hospitalist NP, I’ve been using the same H&P template since I started. I’ve made some small tweaks along the way, but this ensures I don’t forget to ask about anything important, and I always know where to look for the information on my patient. (You can get access to my templates here)

3. Master Verbal Report

As an NP – you will be communicating with physicians and other colleagues much more frequently, and mastering verbal report is essential. Sure – you might have been a nurse for years and know how to give a good NURSING report, but NP-to-Physician report is much different. Physicians are trained specifically to give and get report in a certain way, and unfortunately they can get a bit… testy if we take too long to get to the point or leave out crucial information. The idea it to be concise, but also include the relevant clinical information.

In general – start with their Age, Sex, relevant PMHx, Admission diagnosis, relevant findings, physical assessment, and any recommendations.

Since I work in the hospital, an example of this would be the following:

“86yo Female with a PMHx of HTN, HLD, T2DM, and COPD presenting with cellulitis of right lower extremity calcaneal wound. Initial XR does not indicate Osteomyelitis, MRI is pending, WBC  13, Lactic normal, Blood cultures pending. Patient was started on Zosyn and and vancomycin in the ED.”

After you present the initial basic information, you can specify exactly why you are calling and tailor it to their specific specialty – so obviously if you are calling a nephrologist you would focus on their renal function, blood pressure, electrolytes – etc.

I’m planning on doing a more detailed blog about presenting a patient to another provider whether or as NP or as an RN, so be on the lookout next week!

4. When in Doubt – Cheat!

When I began as a new NP in the hospital setting, I brainstormed the top 20 common diagnosis in my specific specialty. I sat down and made cheat sheets for each diagnosis including information on the etiology, pathophysiology, clinical manifestations, diagnostic findings, and clinical management. You can use textbooks and online resources to find uptodate information – as I said before I recommend UpToDate!

Making these cheat sheets can really help you narrow down specific need-to-know information for your exact clinical role. Making them yourself can help you retain the information. However, if you can’t find the time, the following books have some pretty solid cheat sheets:

These cheat sheets are going to help you look up relevant need-to-know information on the spot while you are at work. Personally, my sheets that I made on Acute kidney injury and hyponatremia have been especially handy in the inpatient setting.

5. Follow the Paper Trail

Whether you work inpatient or outpatient, there will be specialist consultation notes for you to read. You can learn a TON from these notes. These guys are literally specialists, and if you’re a generalist –  you’re kind of the jack of all trades and the master of none. Simply following the paper trail and reading up on your patient’s after you have seen them can help expand your knowledge tremendously.

But don’t only read specialist notes. Working inpatient, theres often medical students and medical resident notes which are very detailed and provide rationale – which Attending physician’s notes often do not have. Don’t write them off simply because they are not attendings. They learn so much in school that unfortunately, we as NPs do not. Reading these notes can be invaluable!

6. Have the Right Attitude

As a new NP, you are the new kid on the block. You need to be humble, ready to learn, confident in yourself but willingly admit when you don’t know. Trust your insticts, but check your ego at the door. We are dealing with patient’s lives here and nothing is more important than hard work, communication, and collaboration with our patients and our knowledgeable colleagues.

There are so many more tips to help new NPs, but I wanted to keep this list short and practical – things that will help you succeed in the clinical setting.

Something that I know will help you guys out as new NPs is signing up for my email list and getting access to my free NP resource library! You’ll be sent a folder with my templates for History and physicals (both inpatient and outpatient), Soap notes, and pronouncement notes. I plan on adding more useful information as time passes, so be sure to check back often!

10 Clinical Calculators for Inpatient Providers

10 Clinical Calculators for Inpatient Providers

Working in a hospital as a provider can be unexpected and stressful. There are so many factors to consider when managing a patient’s acute and chronic diseases. Luckily, there has been a great amount of research involving management of patients within the hospital. There are many different systems and calculations which can help with risk stratification, prevention, diagnosis, and management. These inpatient clinical calculators are sure to be useful to you during your shift in the hospital!

1

Padua Predictive Score for Risk of VTE

Inpatient medicine constantly involves predicting, preventing, diagnosing, and treating blood clots. Venous Thromboembolism (VTE) is the general term used to describe blood clots (thrombi) in the body which may have moved (embolized) to the lungs (pulmonary embolism).

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and 60,000-100,00 American’s die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those >/= 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores greater than 4, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

Check out the Calculator!

2

Wells’ Criteria for DVT

The Wells’ criteria score system is a method to quantify the diagnostic probability for a patient presenting with a DVT/PE, however the calculators are different depending on which you are assessing for.

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT.

Low Probability

Scores of 0 or less have a low-probability of needing further workout to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer result. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless.

https://www.mdcalc.com/wells-criteria-dvt

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. The calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, and malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rule out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

  • Age < 50 years
  • Heart rate < 100 bpm
  • Oxyhemoglobin saturation ≥ 95% on RA
  • No hymoptysis
  • No estrogen use
  • No prior DVT/PE
  • No unilateral leg swelling
  • No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml need further workup (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CTPA, but if this cannot be obtained than a V/Q scan should be ordered.

https://www.mdcalc.com/wells-criteria-pulmonary-embolism

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs, and clots formed in the left atria may embolize to the brain and cause a embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which scores the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

  • Hypertension – 1 point
  • Abnormal renal and/or hepatic function – 1 point each
  • Stroke – 1 point
  • Bleeding tendency/predisposition – 1 point
  • Labile INR on warfarin – 1 point
  • Elderly (age >65) – 1 point
  • Drugs (asa or NSAIDs) and/or alcohol – 1 point each

https://www.mdcalc.com/has-bled-score-major-bleeding-risk

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

  • 0 points – 1.13 bleeds per 100 patient-years
  • 1 point – 1.02 bleeds per 100 patient-years
  • 2 points – 1.88 bleeds per 100 patient-years
  • 3 points – 3.74 bleeds per 100 patient-years
  • 4 points – 8.70 bleeds per 100 patient-years
  • 5-9 points – insufficient data (but high risk)

Remember this decision should be made with specialty consultation to cardiology.

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The treatment of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, and severe AKI/CKD. Treatment in this case involves restricting water, loop diuretics (i.e. IV Lasix), and sometimes medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels.  However, Ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

https://www.mdcalc.com/serum-osmolality-osmolarity

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the calculated sodium level, as once the glucose is corrected the osmotic shifts will resolve.

https://www.mdcalc.com/sodium-correction-hyperglycemia

8

Fractional Excretion of Sodium (FENa)

The Fractional Excretion of Sodium (FENa) is calculated to determine the cause of acute kidney injury (AKI), and is a useful tool that many nephrologists utilize. This can help determine the difference between prerenal AKI from Acute tubular necrosis (ATN). This is calculated from the serum sodium creatinine, and the urine sodium and creatinine.

FENa levels < 1% generally indicate prerenal disease (i.e. decreased bloodflow to kidneys). Levels >2% usually indicates ATN. Levels between 1-2% can indicate both.

Remember that the FENa will not be accurate if the patient is on a diuretic. In general FENa is utilized by Nephrology, but can be useful to calculate if the etiology is unclear.

https://www.mdcalc.com/fractional-excretion-sodium-fena

9

Fractional Excretion of Urea (FEUrea)

The Fractional Excretion of Urea (FEUrea) can be used to differentiate between prerenal AKI and ATN in patients who are on diuretics as FENa will not be accurate. Levels 50-65% generally indicate ATN , and levels <35% indicate prerenal disease.

Again, many factors can determine these tests and they should be interpreted with the consultation of specialists (nephrologists).

https://www.mdcalc.com/fractional-excretion-urea-feurea

10

    Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

Since almost half of the calcium in the bloodstream attached to albumin, abnormal albumin levels will affect serum calcium levels. To correct this, you need to know the patients serum calcium and their albumin level. The calculator will give you a good idea of what their corrected calcium level actually is. So if you see a malnourished patient with an Albumin of 2.0 and a serum calcium of 7.0, the corrected calcium is 8.6 mg/dl.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

https://www.mdcalc.com/calcium-correction-hypoalbuminemia

1

Padua Predictive Score for Risk of VTE

Inpatient medicine constantly involves predicting, preventing, diagnosing, and treating blood clots. Venous Thromboembolism (VTE) is the general term used to describe blood clots (thrombi) in the body which may have moved (embolized) to the lungs (pulmonary embolism).

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and of those 60,000-100,00 die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those ≥ 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores 4 or greater, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

2

Wells’ Criteria for DVT

The Wells’ criteria score system is a method to quantify the diagnostic probability for a patient presenting with a DVT/PE, however the calculators are different depending on which you are assessing for.

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT, as these patients are more likely to develop another one.

Low Probability

Scores of 0 or less have a low-probability of DVT, and thus usually do not warrant further workup to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless. This means that a D-dimer test is not indicated since a Venous Duplex will be obtained regardless.

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. This calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, or malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rules out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

  • Age < 50 years
  • Heart rate < 100 bpm
  • Oxyhemoglobin saturation ≥ 95% on RA
  • No hymoptysis
  • No estrogen use
  • No prior DVT/PE
  • No unilateral leg swelling
  • No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml do (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CT Pulmonary Angiography (CTPA) – but if this cannot be obtained, a V/Q scan should be ordered.

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs and cause a pulmonary embolism, and clots formed in the left atria may embolize to the brain and cause an embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

Remember to always take into account the patient’s risk of major bleeding (see below!)

 

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which quantifies the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

  • Hypertension – 1 point
  • Abnormal renal and/or hepatic function – 1 point each
  • Stroke – 1 point
  • Bleeding tendency/predisposition – 1 point
  • Labile INR on warfarin – 1 point
  • Elderly (age >65) – 1 point
  • Drugs (asa or NSAIDs) and/or alcohol – 1 point each

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

  • 0 points – 1.13 bleeds per 100 patient-years
  • 1 point – 1.02 bleeds per 100 patient-years
  • 2 points – 1.88 bleeds per 100 patient-years
  • 3 points – 3.74 bleeds per 100 patient-years
  • 4 points – 8.70 bleeds per 100 patient-years
  • 5-9 points – insufficient data (but high risk)

Remember the decision for a patient with Afib to not be on oral anticoagulation should be made with specialty consultation.

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The management of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, or severe AKI/CKD. Treatment in this case involves restricting water, administering loop diuretics (i.e. IV Lasix), and sometimes other medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels.  However, ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

 

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the corrected sodium level, as once the glucose is corrected the osmotic shifts will resolve.

8

Maintenance Fluid Rate

As inpatient providers, we have to order IV fluids on many patients. Maintenance fluids may need ordered if the patient is NPO, or if they have fluid losses/dehydration. In order to determine the best rate at which to run the IV fluids, there is a simple calculation. Take their weight in Kg, subtract 20 Kg and add 60mL. Then for every over Kg left, add 1mL. So a 60Kg patient gets 100ml/hr. If this is confusing – you can just use the calculator below!

Keep in mind this rate is a general estimation, and the patient’s own medical history should be taken into account. If they are fluid overloaded (i.e. CHF, Liver cirrhosis, etc), then a slower rate may be more appropriate. Always use your physical examination to guide your management. If the patient is elderly, consider slowing the rate as well. If the patient is having continuous fluid losses (i.e. diarrhea), then consider increasing the rate to 1.5x the maintenance rate – or using your best judgement.

(The calculator also lists the 20ml/kg bolus amount for sepsis patients)

9

Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

Since almost half of the calcium in the bloodstream attached to albumin, abnormal albumin levels will affect serum calcium levels. To correct this, you need to know the patients serum calcium and their albumin level. The calculator will give you a good idea of what their corrected calcium level actually is. So if you see a malnourished patient with an Albumin of 2.0 and a serum calcium of 7.0, the corrected calcium is 8.6 mg/dl.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

10

   Arterial Blood Gas (ABG) Analyzer

Arterial Blood Gases (ABGs) are commonly ordered in patients with respiratory failure in the hospital. This helps clinicians determine etiology and guides management of many respiratory conditions. If you struggle with analyzing ABGs, this calculator can help. Simply input the pH, PaCO2, Bicarb, Sodium, Chloride, and Albumin. This will help you determine whether the ABG abnormality is respiratory, metabolic, and which type with compensation (if any).

It is important for clinicians to be able to analyze blood gases on their own as well. You can read more about ABG interpretation in my ABG guide!

 

If you’re a practicing NP or NP student and need access to my free NP Resource library – sign up here! It has both inpatient and outpatient SOAP note templates, History and physical sheets, death pronouncement notes, and more to come!

References:

Barbar, S., Noventa, F., Rossetto, V., Ferrari, A., Brandolin, B., Perlati, M., … Prandoni, P. (2010). A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. Journal of Thrombosis and Haemostasis, 8(11), 2450-2457. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20738765

Bauer, K. A., & Lip, G. Y. (2019). Overview of the causes of venous thrombosis. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-causes-of-venous-thrombosis

Data and Statistics on Venous Thromboembolism. (2019, August 9). Retrieved August 11, 2019, from https://www.cdc.gov/ncbddd/dvt/data.html

Garcia, D. A., & Crowther, M. (2019). Risks and prevention of bleeding with oral anticoagulants. In UpToDate. Retrieved from https://www.uptodate.com/contents/risks-and-prevention-of-bleeding-with-oral-anticoagulants

Goltzman, D. (2019). Diagnostic approach to hypocalcemia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-approach-to-hypocalcemia

Higgins, C. (2007, July). Ionized calcium. Retrieved from https://acutecaretesting.org/en/articles/ionized-calcium

Hoorn, E. J., & Sterns, R. H. (2019). Causes of hyponatremia without hypotonicity (including pseudohyponatremia). In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hyponatremia-without-hypotonicity-including-pseudohyponatremia

Kearon, C., & Bauer, K. A. (2019). Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-deep-vein-thrombosis-of-the-lower-extremity

Lip, G. Y. (2011). Implications of the CHA2DS2-VASc and HAS-BLED Scores for Thromboprophylaxis in Atrial Fibrillation. The American Journal of Medicine, 124(2), 111-114. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20887966

Manning, W. J., Singer, D. E., & Lip, G. Y. (2019). Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-prevent-thromboembolism

Sterns, R. H. (2019). Causes of hypotonic hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hypotonic-hyponatremia-in-adults

Sterns, R. H. (2019). Overview of the treatment of hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-treatment-of-hyponatremia-in-adults

Sterns, R. H. (2019). General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium balance (hypovolemia and edema). In UpToDate. Retrieved from https://www.uptodate.com/contents/general-principles-of-disorders-of-water-balance-hyponatremia-and-hypernatremia-and-sodium-balance-hypovolemia-and-edema

Sterns, R. H. (n.d.). Diagnostic evaluation of adults with hyponatremia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-evaluation-of-adults-with-hyponatremia

Thompson, B. T., Kabrhel, C., & Pena, C. (2019). Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

Wells, P. S., Anderson, D. R., Bormanis, J., Guy, F., Mitchell, M., Gray, L., … Lewandowski, B. (1997). Value of assessment of pretest probability of deep-vein thrombosis in clinical management. The Lancet, 350(9094), 1795-1798. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed?term=9428249

Yu, A. S., & Stubbs, J. R. (2019). Relation between total and ionized serum calcium concentrations. In UpToDate. Retrieved from https://www.uptodate.com/contents/relation-between-total-and-ionized-serum-calcium-concentrations

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