Nurse Practitioner Notes

Nurse Practitioner Notes Has Been Sold

2008-09-30T20:33:00.003-04:00

Hello to any and all who read this blog. I have sold it to another party. Please click on The Nurse Practitioner's Place to follow me. Thanks for all your support!

Otitis Externa Hints

2008-08-26T21:17:00.002-04:00

Otitis externa is a common occurrence during the summer due to swimming and increased sweating with the heat. It is an inflammation of the auricle, auditory canal and outer surface of the tympanic membrane. It is intensely painful and often resistant to treatment. The majority of cases are unilateral with itching and pain being the predominant symptoms. Sometimes the swelling can be so severe that one must place a wick so that the medication can actually reach the inner canal.

Medications used to treat the condition include the following:

Ofloxacin otic- 10 drops to affected ear BID x 7 days for adults. (5 drops bid for peds)
Cipro Otic - 3 drops to affected ear BID x 7 days (age older than one year)
Cortisporin Otic- 4 drops to affected ear tid/qid x 10 days. (Pedi Otic 3 drops tid/qid)
Auralgan- 2-4 drops tid/qid prn for pain.

Oral meds may need to be used in diabetic patients who are resistant due to increased glucose levels.

Red Bull gives you wings - and heart trouble?

2008-08-15T23:40:00.001-04:00

Red Bull may claim to “give you wings” but drinking too much of the popular energy drink may also lead to heart damage, a study suggests. A study of 30 university students aged between 20 and 24 years old found that drinking just one 250ml sugar-free can of the caffeinated energy drink increased the “stickiness” of the blood and raised the risk...

read more | digg story

Change of Shift is Up!

2008-08-07T21:35:00.001-04:00

Check out the latest Change of Shift!

Controlled Substance List from The DEA

2008-08-03T13:03:00.001-04:00

Ever wondered what is on a controlled substance list? It's especially hard when you are a new NP and don't normally write for these and patients ask for different meds.
Here's the link!

Sample ARNP Protocol

2008-07-25T20:36:00.001-04:00

myflorida - Nursing - ARNP Protocol - Sample Format

ARNP Protocol - (format example)

(Should be no more than 2 to 5 pages)

1. Requiring Authority:

1. Nurse Practice Act, Florida Statutes, Chapter 464
2. Florida Administrative Code, Rules Chapter 64B9-4 Administrative Policies Pertaining to Advanced Registered Nurse Practitioners

II. Parties to Protocol:

(Should only list one ARNP & one Doctor here)

1.

Nancy R. Nurse, ARNP, RN 9999999

123 Main Street

Somewhere, FL 99999
2.

Ian M. Doctor, MD, MX 999999, DEA 999999

Practice Name

456 Center Street

Somewhere, FL 99999

III. Nature of Practice:

This collaborative agreement is to establish and maintain a practice model in which the nurse practitioner will provide health care services under the general supervision of Dr. Ian M. Doctor. This practice shall encompass family practice and shall focus on health screening and supervision, wellness and health education and counseling, and the treatment of common health problems. (Use appropriate description for your specialty and activities) Practice Location(s):

IV. Description of the duties and management areas for which the ARNP is responsible:

A. Duties of the ARNP:

The ARNP may interview clients, obtain and record health histories, perform physical and development assessments, order appropriate diagnostic tests, diagnose health problems, manage the health care of those clients for which she has been educated, provide health teaching and counseling, initiate referrals, and maintain health records. (Specific guidelines for patient care decision making may be referenced here. I.e., ARNP developed practice guidelines, professionally developed guidelines, text books, etc. Do not send these references to the Board of Nursing with protocol agreement.)

B. The conditions for which the ARNP may initiate treatment include, but are not limited to:

Otitis media and externa

Conjunctivitis

Upper respiratory tract infections

Sinusitis

C. Treatments that may be initiated by the ARNP, depending on the patient condition and judgment of the ARNP:

1. Suture of simple and complex lacerations not requiring ligament or tendon repair.
2. Incision and drainage of abscesses.
3. Removal of ingrown toenail.

D. Drug therapies that the ARNP may prescribe, initiate, monitor, alter, or order:

(ARNPs CANNOT PRESCRIBE CONTROLLED SUBSTANCES)

Any prescription medication which is not listed as a controlled substance and which is within the scope of training and knowledge base of the nurse practitioner.

-or –

Antibiotics

Antihypertensives

Etc.

V. Duties of the Physician:

The physician shall provide general supervision for routine health care and management of common health problems, and provide consultation and/or accept referrals for complex health problems. The physician shall be available by telephone or by other communication device when not physically available on the premises. If the physician is not available, his associate, John R. Doctor, MD, MX 999999 (or other description of designated doctor(s) or groups), will serve as backup for consultation, collaboration and/or referral purposes.

VI. Specific Conditions and Requirements for Direct Evaluation

With respect to specific conditions and procedures that require direct evaluation, collaboration, and/or consultation by the physician, the following will serve as a reference guide:

Clinical Guidelines in Family Practice, X Edition, by Constance R. Uphold, ARNP, PhD, and Mary Virginia Graham, ARNP, PhD (or other reference text or practitioner created reference guide)

OR

The physician will be consulted for the following conditions:

3rd degree lacerations

Severe hypertension determined by ____

Etc. (list appropriate conditions)

VII. All parties to this agreement share equally in the responsibility for reviewing treatment protocols as needed and no less than annually.

____________________________/ _______ License # RN9999999

Nancy R. Nurse, ARNP Date

____________________________/ ________ License #ME 999999

Ian M. Doctor, MD Date DEA # 999999

PLEASE NOTE:

Practicing ARNPs must file a protocol at the time of renewal or when there are changes with the Board of Nursing. Alterations or amendments should be signed by all parties and filed with the Board within 30 days.

The protocol and any amendments or changes are to mailed to the ARNP Department, Board of Nursing, 4052 Bald Cypress Way, Bin #C02, Tallahassee, FL 32399-3252. If there are no changes to the protocol, only a dated signature page is needed with a statement that there have been no amendments or changes since the last submission. A copy for each review period should be kept by each party for a period of four years. The supervising physician is responsible for submitting a notice to the Board of Medicine that they have entered into a supervisory relationship with an ARNP.

Mystery Health Care Shoppers, What???

2008-07-07T22:30:00.004-04:00

Here is a huge waste of medical resource money. The article discusses the use of "fake patients" to assess medical providers.
It boggles my mind that 35,000-60,000 is used to have these so called patients go into a practice and pretend to have symptoms in order to evaluate it. It's some kind of mystery medical shopping. I have patients who can't afford health insurance or the medications that they need and they are throwing money away like this! Send me the check instead and let me use it for my patients who really need the help and are REAL patients. ARGH!!

Ways to Relieve Seasonal Allergies

2008-05-17T18:03:00.003-04:00

SINUS ALLERGIES CAUSES: Can be outside &/OR indoor, seasonal OR continuous, and the severity is related to INDIVIDUAL SENSITIVITY, AMOUNT, and TYPE of pollen/mold/mildew/dust/dander in the air. Once your nose is sensitized and swelling has started, even small amounts of extra irritation can cause problems with congestion. Check your home/work for triggers, may need air filter units, removal of carpets (esp in bedroom), vacuum with HEPA or water filter system, wet mopping, swiffer type of duster/floor sweeper. An excellent resource is www.allergy.com. WHY TO TREAT: If allergies are uncontrolled, will lead to sinus infections (viral then bacterial), scarring, growths, &/or polyps.
HOW TO >Start 1-2 weeks before season OR keep taking meds every day
TREAT: >Use LOWEST amount to keep control
>Each medicine works differently, so may need to use combinations for better control
>Taper or stop medications ONLY IF YOU ARE NOT HAVING ANY SYMPTOMS
>May need ENT &/or allergist referral if not controlled with medications
MEDICATION LADDER
MEDICATION TYPE
Nasal Steroid
*Start FIRST & Taper off LAST
Decreases irritation BEFORE SWELLING BEGINS, so best to use early before symptoms get bad. BEST FIRST MEDICATION IF NEEDING CONTINOUS OR SEVERE SEASONAL SYMPTOMS
Leukotriene Inhibitor
*Start/taper SECOND
Stops chemical reaction at start of swelling (before histamines are released), good for added protection if symptoms not controlled with other meds; Used for asthma and sinus allergies.
Singulair 10 mg PO QHS
Antihistamine
*Start/taper SECOND or THIRD
Stops chemical reaction that causes sneezing and MORE swelling, but won’t take care of major symptoms by itself
OTC = Claritin (loratadine)10mg PO daily
OTHER:
Decongestant
Alternative/Additive
*Use first if other meds not working, or after exposure to allergens to stop problems
Excellent for use alone or in combo with decongestants, OK if high BP; Rinses nose to get allergens diluted/out, naturally shrinks tissues with excess swelling/water pulled from tissues due to salt content. CAN’T OVERDOSE OR CAUSE MORE PROBLEMS
OTC = Ocean Mist, Ayr. 2 sprays to each nostril daily/BID
Decongestant
*Use if other meds not working.
Shrinks swelling, helps you to breath. *TAKE FOR ONLY UP TO 5-7 DAYS
**AVOID AFRIN TYPE SPRAYS
(worse congestion due to nose irritation)
***CAN’T TAKE IF HIGH BP
(unless OK with healthcare provider)
OTC = Sudafed, or other meds with Psuedoephedrine, etc

Diabetic Footcare Handout

2008-04-27T14:37:00.001-04:00

I will be posting healthcare educational handouts for NPs to give to their patients from time to time. Feel free to distribute them to others!
Diabetic Foot Care Information
People with diabetes experience higher than normal blood glucose
levels, which can affect the heart, eyes, kidneys and feet. This
handout focuses on why it is especially important that you take
proper care of your feet if you have diabetes.
Two Reasons for Foot Problems
One factor contributing to foot problems in diabetes is nerve
damage, which causes a lack of sensation in your feet. As a result,
you might not feel pain, heat or cold. A minor cut on your foot could
get infected, and you might not even notice.
Another problem you might have is decreased circulation, which
means that less blood flows to your feet, making it harder for
wounds to heal.
Common Foot Problems
If you have diabetes, you’re at greater risk for foot problems that
can lead to infection:
• corns and calluses caused by rubbing or pressure on the same
spot, forming thick layers of skin
• blisters caused by shoes that do not fit properly or by wearing
shoes without socks
• ingrown toenails, which are toenail edges that have grown into
the skin
• dry and cracked skin, caused when nerves in the legs and feet
do not receive the message to keep the feet soft and moist; germs
can then enter through the cracks
• athlete’s foot (caused by a fungus), leading to red, cracked and
itchy skin and thick, yellow and hard-to-cut toenails.
How to Care for Your Feet
Wash your feet every day using warm water and a mild soap.
Use your elbow or a thermometer to check the temperature of the
water — lack of sensation in your feet may prevent you from feeling
when water is too hot. Pat your feet dry with a soft towel.
If the skin on your feet is dry and cracked, use a moisturizing
cream. Check with your nurse practitioner about which kind to use.
Never put the cream between your toes, since this could create an
atmosphere for infection.
Inspect your feet every day for problems. You might need to use
a mirror or enlist the help of someone you trust. Do not try to treat
any foot problems with home remedies.
You may file corns or calluses lightly with a pumice stone or
emery board if your NP says it’s OK. Also, cut your toenails when
needed after you wash your feet, since the toenails will be soft at
that time. Trim straight across, and do not cut them too short. If
your toenails are thick or too hard to cut, your NP can help you.
Wear shoes all the time to avoid irritations that could worsen or
become infected. Do not leave your feet exposed by going barefoot
or wearing sandals. Even at home, you should at least wear hardsoled
slippers. Wear surf shoes at the beach, and remember to
apply sunscreen to the tops of your feet when you are outside to
avoid burns.
Finally, if you smoke, stop immediately. Smoking damages blood
vessels, decreasing circulation to the feet.
The Right Shoes and Socks
Poorly fitting shoes can cause injury or irritation. Buy shoes that
fit correctly — you should be able to wiggle your toes in them.
Avoid plastic shoes since they don’t stretch and your feet cannot
breathe. Instead, choose leather or canvas shoes to support your
feet and let air in and out.
Break in your new shoes gradually. In addition, inspect each shoe
every day before you insert your foot. Make sure there are no torn
linings or foreign objects, such as a tack or a pebble.
Always wear cotton or wool socks with your shoes to avoid blisters.
Socks should fit loosely and leave no marks on your skin.
Stockings can also be worn. Make sure they are not too tight — they
shouldn’t leave marks on your skin, either. In some cases, you may
need inserts or even custom shoes to help with your foot problems.
Avoid the Worst-Case Scenario
Schedule a visit with your NP if you are having a problem with
your feet that won’t go away. If you avoid treating the problems,
your feet could become infected, and poor blood flow could slow
the healing process. Make sure you get your feet treated so that you
can avoid severe complications such as amputation.
Retrieved from http://nurse-practitioners.advanceweb.com/

NPs Need Prescriptive Rights

2008-02-03T14:42:00.000-05:00

The following is a copy of a letter that we all need to send to the Florida Senators so that NPs can finally treat our entire patient! I hope that you copy and make whatever insertions or opinions and forward to them as well. Any patients who feel the same way, please send a letter from you as well letting them know that you are tired of not being taken care of properly and it's high time that Florida get on board with the rest of the USA. It's one of the last three states holding out. The addresses to the Florida Senators are at the bottom!

There is a shortage of healthcare providers in Florida. There are significantly fewer physicians and advance practice nurses and medically underserved populations as defined by the Department of Health and Human Services are the areas in which these shortages are most acutely felt. SB 972/ HB 515 by Senator Saunders and Representative Zapata is intended to improve patients access to care by permitting controlled substance prescriptive privileges for ARNPs whose practice location is in Medically Underserved Areas and Medically Underserved Populations as defined by Health and Human Services.

This bill allows ARNPs to meet the needs of their patients who require scheduled medications either for pain control, side effect management such as diarrhea, behavior modifications such as anxiety or attention deficient hyperactivity disorders.
Florida ARNPs have been prescribing medications with the exception of scheduled drugs since 1987. ARNPs are authorized to prescribe through a collaborative practice agreement with a physician licensed under Chapter 458 or 459 and may only prescribe those medications used within their scope of practice and contained within the protocol. However, ARNPs are educated to prescribe controlled substances along with other medications.

Nurse practitioners must pass two rigorous national certification exams before they can practice in this capacity. Nurse practitioners have been proven, in well controlled studies, to be as safe as physicians in providing care to patients.
As states have begun to allow ARNPs to prescribe controlled substances, no state has withdrawn or limited the ARNPs ability to prescribe. There has been no indication in any state that authorizing nurse practitioners to prescribe controlled substances directly increases prescription drug abuse. Florida is one of only three states which do not allow ARNPs to prescribe these medications to their patients who require them.
Schedule II: includes commonly used medications such as Adderal and Ritalin for management of Attention Deficit Diorder (ADD); Demerol and morphine for pain management.
Schedule III: includes medications such as vicoden and Tylenol with codeine for patients with moderate pain levels.
Schedule IV: includes ativan, xanax and valium for anxiety, ambien for sleep disorders and darvocet for mild to moderate pain.
Schedule V: includes medications such as Robitussin AC for cough and Lomotil for diarrhea.

I think that my patients deserve to be completely taken care of by their primary care provider. I cannot do that in the current practice setting of Florida. It’s a shame that such a progressive state is one of the three states left in the entire country that continues to restrict Nurse Practitioners. My patients ,who are in a rural setting, cannot afford to pay a separate (much higher) fee in order to have a tolerable, or hopefully better, quality of life.

Thank you very much for taking the time to read this letter. Please support this bill and prove to Floridians that we do care for every citizen.

Senator Nelson
225 E. Robinson St., Ste. 410
Orlando, FL 32801

716 Hart Senate Office Building
Washington, D.C. 20510-0905

Senator Martinez
356 Russell Senate Office Building
Washington, D.C. 20510-0903

1650 Prudential Dr., Ste. 220
Jacksonville, FL 32207

Examination of Head and Neck For Nurse Practitioner Students Part 2

2007-12-13T21:30:00.001-05:00

History for Mouth and Pharynx: Dentures, frequent sore throats, halitosis, change in taste, swollen or bleeding gums, mouth or tongue ulcers, dysphagia, patterns of dental care.
Inspect and Palpate the Mouth and Pharynx
· Lips - inspect for color, moisture, swelling, cracking, lesions. Cracking may be Vitamin B deficiency/ dehydration/ braces.
· Bucchal Mucosa - inspect for color, ulcers, nodules. Check floor of mouth - most common site for oral malignancies. Tobacco chewers and smokers are at high risk. Cancer sores (aphthous ulcers) are common on bucchal mucosa and tongue, painful, last for 5-10 days. Causes include stress, trauma, acidic foods. Treat with topical corticosteroid paste such as Triamcinolone (Kenalor in Orabase 0.1%).
· Salivary Glands - should emit clear fluid
o Parotid ducts (Stensen's Ducts) - adjacent to upper molars
o Submaxillary ducts (Wharton's Ducts) - under tongue
· Gums and teeth - inspect gums for swelling, bleeding, retraction, discoloration. Should have 32 teeth.
· Pharynx - check hard, soft palate and uvula for color, contour, symmetry and movement. Ask patient to say "ah". Damage to the glossopharyngeal or vagus nerve (CN IX, X) can cause the soft palate not to rise and uvula to deviate to the uninvolved side. Check tonsils for size, color, lesions.
· Tongue - check for color and smoothness
o Vallate Papillae - seen on posterior dorsum of tongue
o Glossitis - smooth, red tongue suggesting a vitamin deficiency of B12/ niacin/ iron, or drug reaction.
o CN XII (Hypoglossal) - have patient stick tongue out - deviation to one side suggests paralysis of the cranial nerve.
o Leukoplakia - white patches most commonly seen on underside of tongue. They are pre-malignant.
o Thrush - white patches that are generalized over entire mouth. Mucosa is red and painful. Caused by yeast. Commonly seen in children following antibiotic therapy. Also seen in HIV patients.
History for the Neck: neck injury, pain or stiffness; tender or swollen lymph nodes, HA
Inspect and Palpate the Neck
· Muscles - inspect for symmetry, masses and swelling
o Sternocleidomastoid - extend from top of sternum to mastoid process. Responsible for turning the head side to side, and forward flexion of the neck. Divides the neck into 2 triangles. Innervated by CN XI (Spinal Accessory)
§ anterior triangle - trachea, thyroid gland, anterior cervical nodes, carotid artery.
§ posterior triangle - posterior cervical nodes
o Trapezius - extend from the occipital bone to the 7th cervical vertebra and attaches to all thoracic vertebrae, clavicle and scapula. Responsible for shoulder shrugging, backward tilt of the head and raising of the chin, tilting head side to side. Innervated by CN XI.
· ROM - flexion, extension, rotation, lateral bending
· Muscle Strength - turn head, shrug shoulders against resistance
· Lymph Nodes
o pre-auricular - drains eyes and ears
o posterior auricular - drains ear and scalp
o occipital - drains scalp and neck
o tonsillar - drains mouth and nose
o submaxillary - drains mouth and nose
o submental - drains tongue
o superficial cervical - drains ear and scalp
o posterior cervical - drains ear and scalp
o deep cervical - drains mouth, ears and scalp
o supraclavicular - all of above, abdomen, breast, thorax, arm
*Palpate nodes with patient's head bent slightly forward. Note their size, shape, mobility, consistency, and tenderness. Can be normal to feel small, mobile, non-tender nodes. Enlarged, tender nodes indicate infection. Enlarged, hard, fixed nodes indicate malignancy.
Inspect and Palpate the Thyroid and Trachea - palpate for size, shape, symmetry, tenderness and nodules. Located just below cricoid cartilage. Normal thyroid is barely palpable due to the fact that much of the lobes are covered by the sternocleidomastoid muscles. Palpate the thyroid with patient's neck slightly flexed. Ask patient to swallow - thyroid will rise with swallowing.
· Thyroid - butterfly shaped gland. Isthmus lies over the trachea but blends in with tracheal rings and can't be palpated. Lateral portions curve backward and are covered by sternocleidomastoid muscles. Produces T3 and T4 = T7. Thyroid Stimulating Hormone (TSH), produced by the pituitary gland, stimulates the thyroid to produce T3 and T4. Works as a feedback loop.
o enlargement - may be diffusely enlarged in hyperthyroidism and goiter.
o hypothyroid - signs and symptoms include wt gain, cold intolerance, fatigue, dry skin and hair, poor hair growth, constipation, depressed deep tendon reflexes (DTR), mood swings, menorrhagia, periorbital edema, bradycardia, and possibly CHF.
o hyperthyroid - weight loss, heat intolerance, muscle fatigue, insomnia, increased sweating, polyphagia, increased bowel movements, restlessness, irritability, hyperreflexic, tremor, exophthalmos, lid lag, amenorrhea, tachycardia, arrhythmias, palpitations.
o asymmetry - asymmetrical enlargement or nodules may be indicative of malignancy.
· Trachea - inspect and palpate for deviation which may result from masses in the neck, pleural and pulmonary abnormalities, particularly pneumothorax.
History for the Ear:discharge or excess cerumen, infections, PE tubes, itching, tinnitus, otalgia, vertigo, excessive noise exposure, hearing loss in patient or family, use of hearing aids, cleaning habits, tobacco use, use of ototoxic drugs, recent flying or scuba diving
Anatomy - Review structure and function of the 3 compartments.
·External ear - auricle and ear canal
·Middle ear - starts at tympanic membrane (TM) and is connected to the nasopharynx by the Eustachian tube.It is an air filled cavity across which sound is transmitted by way of the 3 tiny bones:
oMalleus
oIncus
oStapes
·Inner ear - transmits nerve impulses to brain via the cochlear nerve.Inner ear is also important in controlling equilibrium.
Inspect and Palpate Auricle - for deformities, lumps, skin lesions. Helix is common site for skin cancers due to sun exposure.
Inspect Ear Canal and Ear Drum
1. Canal - pull auricle up and out for adults, down and out for children. Check for inflammation, exudate, foreign body.
oExternal Otitis (swimmers ear) - marked by inflammation and white exudate, pressure on the tragus is painful. Excessive moisture and high ambient temperatures is most common cause. Excessive cleansing of the protective cerumen is another common cause. Usual causative organisms are pseudomonas, proteus, occasionally staph and strep. Treat by washing excess exudate first, then using antibiotic-steroid gtts. For severe cases, an antibiotic wick may be placed in the ear canal.If infection and inflammation extend outside the canal, an oral antibiotic is recommended.
o Foreign Body - particularly prevalent in the pediatric population. Beads, toys, food, other small objects can set up inflammation and pain particularly if it is pushed up against the tympanic membrane. Insects are also a common cause and can be quite uncomfortable if they are still living. The foreign body must be removed with forceps or ear lavage.
o Cerumen Impaction - common in the elderly who wear hearing aids. Each time the hearing aid is placed in the ear, any cerumen that is present is pushed down into the canal. Eventually occludes the canal and causes pain and loss of hearing.
2. TM - check for color, landmarks, fluid levels, air bubbles.
· Serous Otitis Media - fluid present behind the TM. May clear with decongestants.
· Acute Purulent Otitis Media or Otitis Media with Effusion - red TM, bulging with distortion of the bony landmarks. Probably fever especially in children. Causative organisms are pneumococcus (most common), H. flu, Branhamella catarrhalis, strep and staph. Most common treatment drugs are cephalosporins and sulfa drugs. Complications: anyone who develops or has persistence of any of the following symptoms while on antibiotics should be suspicious of an intracranial complication like meningitis, encephalitis, brain abcess or flu due to one of many new viral strains: headache, lethargy, malaise, irritability, nausea and vomiting, onset of fever.
· Bullous Myringitis - characterized by vesicles on TM - usually caused by mycoplasma bacteria. Treat with oral antibiotics.
· Myringotomy - an incision is made in the eardrum - generally for PE tubes.
· Perforations - secondary to infection or trauma. Usually heal spontaneously, delayed healing > 3 months, may need tympanoplasty.
· Scarring - chalky white patches from past infections or dark thin spots from old perforations.
· Cholesteatoma - a cyst-like sac filled with epithelial cells and cholesterol that can occur in the meninges, CNS, bones of the skull, but most commonly enlarges to occlude the middle ear. Enzymes formed within the sac causing erosion of adjacent bones, resulting in deafness. Can be congenital or acquired. May be symptomatic for many years except for progressive hearing loss. May c/o tinnitus, fullness in the ear. Cholesteatomas appear as white, shiny, greasy, flakes of debris in the posteriosuperior quadrant of the TM. May also be accompanied by polyps and a foul smelling discharge. Treatment is surgical.

Examination of Head and Neck For Nurse Practitioner Students

2007-12-13T21:27:00.000-05:00

Examination of Head and Neck
History for Head: frequent HA, trauma, dizziness, syncope, loss of consciousness
· Inspect and Palpate the Head - size, shape, position of eyes, ears, nose and mouth. Note any swelling or asymmetry.
· Acromegaly (excess growth hormone) - produces enlargement of both bone and soft tissue. Elongation of head with bony prominence of forehead, nose and jaw. Soft tissue of nose, lips and ears enlarge.
· Hydrocephaly - increased fluid within the ventricles of the brain.
· Hypothyroidism (myxedema) - dull, puffy face with periorbital edema. Skin is dry, hair course, eyebrows thin on outside.
· Cushing's Syndrome (excess adrenal hormone production) - moon face, red cheeks, possible mustache. Iatrogenic in patients taking long term, large doses of Prednisone.
· Parkinson's - decreased facial mobility giving "mask face" appearance with decreased blinking, stare with head flexed forward.
· Bell's Palsy - results from a paralysis of CN VII. The eye on the affected side cannot close completely, lower eyelid droops, corner of the mouth droops.
· Temporal Arteries - palpate and auscultate the temporal arteries for tenderness and bruits. Temporal arteritis can cause blindness and immediate referral is necessary.
· Temperomandibular Joint - palpate the TMJ for tenderness, crepitus, strength (CN V)
History for Nose: olfaction, nose bleeds, allergies, post nasal drip (PND), frequent colds or sinusitis.
Inspect the Nose: Upper 1/3 is bone, the remainder is cartilage
· Nasal mucosa - note color (normally dark pink), swelling, exudate, bleeding
· Turbinates - winding cavities from outside to pharynx, purpose is to increase surface area of nose for filtration. Inspect for deformity, asymmetry, inflammation. Use otoscope with wide nasal speculum. Can visualize middle and inferior turbinates but not superior.
· Septum - note any bleeding, perforation, deviation. Septal deviation is not significant if there is no airway obstruction
o acute rhinitis (cold) - thick yellow or green nasal discharge, often fever, mucosa red and swollen.
o allergic rhinitis - clear, watery nasal discharge, no fever, mucosa pale and boggy.
Palpate the Sinuses - tender in acute sinusitis. May complain of teeth hurting. Purulent discharge, nasal stuffiness, fever, malaise.
· Maxillary - under cheeks
· Frontal - over eyes
*Can't directly palpate ethnoid and sphenoid sinuses
Special Maneuvers: Transillumination of the sinuses is accomplishes in a slightly darkened room. A bright focused light is placed directly on the cheek over the maxillary sinuses. The patients mouth is open and the examiner looks for a light glow on the roof of the mouth. Diminished light may indicate full sinus cavities. Unequal light may indicate unilateral sinus fullness. For the frontal sinuses, the light is placed in the upper nasal orbit while the examiner looks for the glow in the frontal sinuses.

Sample Patient Assessment Template

2007-11-02T13:54:00.000-04:00

Below is a sample visit template.

Patient:
Date 13 June 2006

Present Illness/ Review of Symptoms:

Patient presents today with...

Review of Symptoms: A 14 point review of symptoms is otherwise negative.

Physical Exam: Vital Signs: Stable see chart
General Well Developed well nourished, positive affect, no acute distress.
Neuro: Alert and oriented X 3, Cranial nerves II-XII grossly in tact, MAE without difficulty, negative ataxia or cerebellar signs, normal gait and sensorium.
HEENT: NC/AT, eyes clear, TMs clear with visible landmarks, Nasal septum midline with patent nares, oropharynx clear, mucous membranes moist, the maxillary and frontal sinuses are non tender to palpation.
Neck: Supple, full ROM, no JVD, no thyromegaly, no lymphadenopathy.
Lungs: Clear bilaterally, regular equal and unlabored, normal rate and depth of respiration.
CV: S1 and S2, no murmurs, regular rate and rhythm.
Abdomen: Non distended, Non- tender to palpation, bowel sounds present X 4 quadrants, no focal signs, no HSM. GU: No CVA tenderness. Skin: Warm and dry, no rash or xanthem noted. Extremities: No edema, negative Homan’s sign, 5/5 strength upper and lower extremities.

Diagnostics:

Assessment

Plan

Patient was educated regarding the treatment plan, and was instructed to seek care immediately in case of changing or worsening symptoms. As always, we remain available for questions or concerns.

________________________________________________
Sign Here

2007 Nurse Practitioner Salaries

2007-10-26T16:29:00.000-04:00

Below is supposed to be the average salaries of Nurse Practitioners in the Gainesville,FL area. I don't think that the salaries are that high. The most I've made as a new grad has been 73,000 in Family Practice. Of course, if this is the most correct numbers, I would more than happily commute to Gainesville for a job. Seriously, I'm looking for a job right now. Serious inquires only.

Nurse Practitioner Family Practice in Gainesville, FL
$97,000
Nurse Practitioner Aprn RN in Gainesville, FL
$54,000
Permanent Family Nurse Practitioner in Gainesville, FL
$54,000
Calling Nurse Nurse Manager in Gainesville, FL
$56,000
RN Practitioner in Gainesville, FL
$92,000
Rhc Midlevel Practitioner in Gainesville, FL
$79,000
Geriatric Nurse Practitioner NP in Gainesville, FL
$75,000
Professional Nurse Practitioner in Gainesville, FL
$61,000
Charge Nurse Skilled Nursing in Gainesville, FL
$71,000
Nurse Practitioner Physician Assistant in Gainesville, FL
$83,000
RN Infection Control Practitioner in Gainesville, FL
$62,000
Family Nurse Practitioner in Gainesville, FL
$68,000
Nurse Practitioner in Gainesville, FL
$69,000
Pediatric Nurse Practitioner in Gainesville, FL
$82,000
Neonatal Nurse Practitioner in Gainesville, FL
$79,000

What Is A Nurse Practitioner?

2007-10-26T16:16:00.000-04:00

What's a Nurse Practitioner (A.R.N.P.)

A Nurse Practitioner is a Professional Registered Nurse who has advanced education and clinical training in a health care specialty. Florida Board of Medicine designates the term for the nurse practitioner as "A.R.N.P" or Advanced Registered Nurse Practitioner. Most Nurse Practitioners have national board certification in their area of expertise and hold Master's or Doctoral degrees. Nurse Practitioners serve as primary health care providers for children and adults during health and illness. Their goal is to help people of all ages stay as healthy as possible. They do this by teaching people and treating their acute illnesses (such as infections) and chronic disease (such as hypertension, diabetes, and many others).

What can a Nurse Practitioner do?

Physical examination, treatment & procedures%u2022 Order and interpret laboratory and diagnostic studies,Family planning service,Healthcare during pregnancy,Well/sick care for all ages,Health risk evaluation,Psychological counseling,Coordination of health care services,Health education,and Fitness for duty examinations

Can Nurse Practitioners prescribe medications?

Yes. How a Nurse Practitioner prescribes medications is regulated by each state's Nurse Practice Act. In Florida, Nurse Practitioners have prescriptive authority through written agreements with a collaborating physician. In Florida, ARNP's are restricted and cannot prescribe controlled substances. Through legislation, we are working on this.

Why Choose a Nurse Practitioner?

Nurse Practitioners are also trained to promote health and prevent disease through comprehensive health care and education. More and more people are choosing a Nurse Practitioner for their regular health care provider because Nurse Practitioners are highly trained health professionals who:take time to listen to you and your family's worries and concerns, explain the details of health problems, medications, and other topics to help you understand how to take care of yourself,provide individualized care,work in collaboration with physicians and other health professionals to insure that you receive the best possible health carereally care about you, your health, your family, and the community you live in,treat you when you are sick,teach you how to care for yourself when ill and how to stay healthy

Contact the Florida Nurse Practitioner Network to locate a ARNP for your health or referral for a family member.
Retrieved from www.fnpn.org

Diabetes Partnership Agreement for Nurse Practitioners

2007-10-21T21:50:00.000-04:00

Below is a diabetes partnership agreement that I found on I changed the wording to say health care provider instead of physician to include nurse practitioners because we provide the same care for diabetics. Hope it is helpful. I think that it is a great template for other health issues as well.

Patient-health care provider partnership agreement for diabetes management

OBJECTIVE
To better manage your diabetes through a patient-physician partnership and goal setting.

REASON
Medical research and clinical experience have shown that optimal management of diabetes significantly reduces the known
complications of this disease, including blindness, heart attack, kidney failure and loss of a limb.

EXPECTATIONS
You can expect your physician to provide the following services, which are an essential part of diabetes management.
• OFFICE VISITS - every three months for reviewing your progress.
• MONITORING - blood pressure, other vital signs, foot examination and A1C.
• ANNUAL SCREENING - lipids, microalbuminuria (test for kidney protein), eye examination and monofilament testing (sensory
examination of feet).
PERSONAL GOALS
Weight/Body Mass Index: Current:________/________ Ideal:________/________
A1C (< 6.0 percent): Current:__________ Goal for 6 months:__________
Blood pressure (< 130/80 mm/Hg): Current:__________ Goal:__________
Total cholesterol (< 200 mg/dl): Current:__________ Goal:__________
LDL (< 100 mg/dl): Current:__________ Goal:__________
YOUR RESPONSIBILITIES
• Schedule follow-up appointments every three months or as indicated by your doctor.
• Monitor blood sugars at home at the agreed testing frequency: _____________________.
• Work toward attaining the personal goals noted above.

PATIENT SIGNATURE _________________________________________ Date:______________
HEALTH CARE PROVIDER SIGNATURE ______________________________________ Date:______________

What do you want to find here on this nurse practitioner blog?

2007-10-17T23:22:00.000-04:00

I haven't gotten any comments on this site so far.. What do you want to see posted here? Let me know!

Applying for a Nurse Practitioner's NPI number

2007-10-03T17:47:00.000-04:00

Hope this information helps other NPs get their needed NPI number! I'll update about what's been going on a little later.. Breaking news!

TO:Florida NP’s

FROM:ANA/FNA

DATE: January 29, 2007

RE: National Provider Identifier (NPI) Deadline Approaching

If you bill for services, you probably need National Provider Identifier (NPI). If you bill Medicare for services, you definitely need an NPI! Getting an NPI is easy. Getting an NPI is free. The first step is to get your NPI. Once you obtain your NPI, it is estimated that it will take 120 days to do the remaining work to use it. This includes working on your internal billing systems, coordinating with billing services, vendors, and clearinghouses and testing with payers. As outlined in the federal regulation, implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you must also share their NPI with other providers, health plans, clearinghouses and any entity that may need it for billing purposes.

If you delay applying for your NPI, you risk your cash flow and that of your health care partners as well. Providers have until May 23, 2007, before you are required to submit claims with only an NPI. Information available on the CMS website: If you are not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found at the Centers for Medicare and Medicaid Services (CMS) NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. In addition, a new Special Edition MLN Matters article is now posted on the (CMS) website with important information for Medicare providers, as well as information that may be helpful for all health care providers. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.

It's Time For Change of Shift at Emergiblog!

2007-09-21T07:44:00.000-04:00

It's time for Change of Shift over at Emergiblog! Enjoy...

Nurse Practitioner Student Writeup Vaginal Candidiasis

2007-09-20T20:29:00.000-04:00

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

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

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

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

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

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

Medical Diagnosis: Candidiasis infection

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

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

Pharyngitis Writeup for Nurse Practitioners

2007-09-17T21:49:00.000-04:00

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

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

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

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

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

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

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

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

DX: Tonsillitis, Pharyngitis

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

Skin, Abdominal, Musculoskeletal Writeup

2007-09-06T21:00:00.000-04:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why Should A Nurse Further Her Degree?

2007-09-06T07:53:00.001-04:00

A reader asked over at Nurse Zone.

Dear Stephanie,

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

- Elka

Stephanie Thibeault, RN, BSN and author responded:

Hi Elka,

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

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

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

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

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

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

Nurse Practitioner Practice Expansion in Pennsylvania

2006-12-12T16:22:00.000-05:00

By Tracie Mauriello, Pittsburgh Post-Gazette

HARRISBURG -- Nurse practitioners soon could play a bigger role in health care in Pennsylvania.

Gov. Ed Rendell wants to revamp healthcare in Pennsylvania, starting with a change in regulations that restrict treatment by nurse practitioners, who charge less than physicians.

Mr. Rendell expects to unveil a plan in January, but he provided a glimpse yesterday during his traditional year-end news conference.

"The test for us is, are we going to have the intestinal fortitude to look down the barrel of special interests and say, 'Uh-uh guys, not this time. Health care is too important of an issue," Mr. Rendell said.

"I want to free nurse practitioners to do anything they are capable of doing," Mr. Rendell said.

To read the rest of the story.. Click

This is very important to Pennsylvania NPs. I'm all for expansion of practice but I still believe that we should continue to collaborate with doctors in order to provide excellent care for our patients. I know that many NPs would like to sever the connection, but I think that it's important to have someone to discuss complicated cases with. Maybe my opinion will change in the future when I have more experience, but I'll have to see.