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    L Jane Acree

Orthopedic Nursing – SO Rewarding!

Orthopaedic nursing might include more options than you thought.

From birth to death, people can have musculoskeletal problems. And you can be the one to help them through the roughest part and get them on the road to a more normal life.

What types of patients might orthopedic nurses see?

Most people have a good idea, but let us just list some of the musculoskeletal conditions which ortho nurses typically serve:

  • Arthritis and Osteoporosiship-xray
  • Fractures
  • Genetic malformations
  • Degenerative Joint Disease
  • Joint replacements
  • Degenerative Disc Disease
  • Back Surgeries
  • Muscular Dystrophy

Of course, ortho patients also typically bring their other ailments with them – and the list of those conditions is almost limitless. Be sure – your med-surg skills will still be needed.

How might you engage with your ortho patients?

If you work on the ortho floor you can expect to:

  • Create and follow care plans according to condition
  • Administer transfusions
  • Drain care
  • Control post-op pain
  • Monitor response to anticoagulation therapy
  • Educate, demonstrate, reinforce, explain, and teach again
  • Manage and assist with equipment use

On a rehab unit, you will do more of the same with more emphasis on dismissal preparedness.

What roles might you consider as an orthopaedic nurse?

Of course, you will be highly sought after if there is a local or national disaster and there are bone injuries. But in a more traditional sense, the roles of the orthopaedic nurses are quite varied as seen below:

  • Floor nurses
  • Charge nurses
  • OR ortho nurses
  • Clinical nurse specialists
  • Nurse managers
  • Nurse directors
  • Nursing educators
  • RN first assistants
  • Case managers
  • Nurse practitioners
  • Office managers

In what settings might orthopaedic nurses work?

Besides the two mentioned above, orthopaedic nurses may work in a variety of settings. Some of these include:

  • Emergency departments or trauma units
  • Operating rooms
  • Orthopaedic units for adults
  • Orthopaedic units for peds
  • Traditional med/surg units
  • Med/surg units for peds
  • Geri units
  • Rehab units
  • Nursing homes
  • Oncology units
  • Home health agencies
  • Nursing colleges or universities

If you like equipment, ortho nursing will be fun for you. It utilizes a variety of assistive and therapeutic devices.


Nurses may enter the orthopedic field as either RN or LPN/LVN. Many nurses become Orthopaedic Nurse Certified (ONC) by passing a certification exam, after two years of ortho experience, through the Orthopaedic Nursing Certification Board (ONCB).

Some may choose to earn their advanced practice nursing certifications as either Orthopaedic Nurse Practitioner (ONP-C) or Orthopaedic Clinical Nurse Specialist (OCNS-C). Still others go on farther.

What is an orthopaedic nurse worth in dollars?

Orthopaedic nurses are said to enter the field at an average salary of $80,000 to $81,000/year (compared to the national average of $65,000/year for med/surg nurses.) They say it is the sixth highest paid nursing specialty.

Of course, some orthopedic nurse salary elements that should be taken into account are the actual duties and responsibilities of the nurse.

Here is a link to one of the very best YouTube videos on various types of ortho surgeries. It explains why sometimes similar ortho cases are treated so differently – especiall as it pertains to specific weight bearing orders. https://www.youtube.com/watch?v=dOPemoiWDgE








Clinical Nurse Specialist – Want to?

Clinical Nurse Specialists (CNS) are Advanced Practice nurses who have earned an MA, MS, or doctoral degree in nursing plus their certification in a specialized area of nursing practice.

Their certification could be one of a wide range of clinical practice areas such as: women’s health, orthopedics, geriatrics, emergency care, psychiatry, oncology, diabetes, rehabilitation, wound care, stress, pain, and so on.

A CNS may practice in a wide variety of settings, such as: hospitals, facilities for community health, education, long term care, mental health, occupational health, and also in private practice.

CNS’ are clinical experts, educators, consultants, and researchers. They utilize their education to influence outcomes, to increase quality of care, and to improve the cost effectiveness andlab coat over pink scrubs outcomes for patients, nurses, and organizations.

In addition to performing a lot of administrative and program development duties, the CNS might also provide direct patient care. A CNS might typically work with nursing personnel – mostly in an educational capacity.

CNS’ may apply for prescriptive authority if they meet the required criteria, and some locations allow third party reimbursement for CNS services.

National Association of Clinical Nurse Specialists (NACNS) and other specialty organizations offer excellent direction when looking for information on advancing your degree and becoming a CNS.

When it comes time for certification training, you will want to choose carefully and remain focused on your specialty area.

You might look into American Nurses Credentialing Center, the Acute Care/Critical Care certification by the American Association of Critical Care Nurses who offer certification courses.

Two more examples are the Oncology Nursing Certification Corporation and the Association of Orthopedic Nurses.

To summarize, Clinical Nurse Specialists may serve as expert consultants for nursing staffs and take an active role in improving health-care delivery systems – even up to the governmental level.

A CNS earns an average of $58,000 – $100,000 per year. This, of course, would vary depending on local circumstances. The job market is excellent for this field. The current demand actually is greater than the supply.

 I hope this helps! Always add your expertise in the comments section.









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The Leap from Geri RN to Geri NP

As many of our doctors retire, several are being replaced by nurse practitioners. Comparative studies show that patient outcomes are nearly equal whether cared for by NP’s or MD’s.

NP’s are stepping up to fill the growing healthcare needs of the many Boomers coming up. So let us compare privileges and duties of RN’s vs NP’s.


Geri RN                                                          vs                               Adult Gerontological NP

Time spent with each patient

All day – off and on Usually less than 60 minutes per patient at 10-25 patients per day


Types of duties

Physical lifting, turning, aid, fall prevention, medication administration, specimen collections, perform nursing procedures, wound care, education, and other duties as assigned

Assess patients, analyze test results, diagnose, write orders, evaluate & adjust treatment plan, admit and discharge patients, write prescriptions, instruct bedside nurse if needed, update supervisory MD per protocol


Required education level

State-Licensed LVN, ADN, RN, or BSN – general nursing degree and state licensure Must already have at least State-Licensed BSN with good GPA, followed by Master’s Degree, then Post Graduate Certificate – gerontology nurse practitioner major, earn Advanced Practice Nursing License- takes ~ 1-3 yrs. Training may be flexible depending on your college & specialty area.


Certification Needed

None required – optional          Through Advanced practice registered nurses          (APRN), American Nurses Credentialing                  Center (ANCC), and American Association              of Nurse Practitioners (AANP) gerontology


Prerequisites to Enter Program

College program-required prerequisites for desired degree 1-2 years RN experience after licensure, BSN degree



Carry out orders received from MD’s NP’s, and PA’s, delegate some duties to nurses’ aide Dictate and oversee course of emergency and routine care, write orders, write prescriptions, perform certain medical skills – with or without a supervisory MD


Technical Skills

Nursing assessments, apply nursing diagnosis, follow orders for nurse, assure other orders are carried out by departments, report all abnormals to NP, administer medications and treatments as ordered, educate patients and families, see to all areas of patient safety, hygiene, and well-being Advanced physical exams and assessments, Diagnose, Expert in performing & Analyzing ECGs, expert in all forms of O2 delivery equipment, nebulizers, IV equipment, and ambulatory assistive devices. Run a code, analyze ABGs, X-rays, and other tests – plus medical treatments as needed (ie: insert chest tubes) after specialized training and certification


Average pay in USA

$62,000/year $95,000/year


Job Roles and Work Environments

Follow orders of MD, PA, or NP in clinics, hospitals, urgent care, ER, ambulance, emergency aircraft, nursing homes, assisted living facilities, long term care, home health, hospice, run certain types of private practices – such as aesthetic or holistic nursing, low to mid management, facilities and other  environments PCP/Ordering Clinician in clinic, hospital, ER, urgent care, nursing homes, assisted living facilities, long term care facilities, with home health companies, hospice, run your own private practice, may work in leadership or administrative roles, usually sole provider in ambulance or emergency aircraft situations


Would you like to join the ranks and enjoy the privileges? You already care for elderly patients every day. So why not take that extra step?

Thanks for taking a look! I hope this helps somebody! Give me a shout-out if you have additional input!








Little-Known Assessment Tricks to Verify Pain in Dementia Patients Part 2 of 2

Part 2 of 2

Numerous studies of dementia patients have shown the obvious – that effective pain002 management is very likely to decrease disruptive behaviors in this population.

Most nurses experience a degree of frustration when trying to accurately assess for pain in the cognitively impaired because they know that the hope of this vulnerable population is in their hands.

Although treating just the behavioral problems does sometimes alleviate the conduct for a while, the patient might still be suffering with untreated pain.

When possible, a primary caregiver or proxy is valuable to assist with pain assessments. Usually they know the patient very well and should be included. Nevertheless, we all prefer some form of self-reporting.

When self-report is not possible, observation of pain-related behavior is a valuable approach to identification of pain in dementia.

You have, of course, noticed many types of pain responses. But watch the faces.

eyes blue redPain reflexes and facial responses to painful stimuli are valuable clues in mild to moderate AD patients. (Unfortunately, they have found fewer of these signs in the more severe AD patients.)

One may assess, for example, chronic pain to the musculoskeletal system through gentle guided movements while feeling for muscle resistance and watching for facial expression changes. Expand that concept to abdominal assessments, etc.

The American Geriatrics Society (AGS) studied the various behavioral expressions of pain in the elderly. They examined facial expressions, body movements and vocalizations.

They found facial movements were the most consistently helpful when developing pain-assessment tools for dementia patients.

Pain perception in this group can be noted in the face. This is especially helpful in examining movements around the eyes, and specifically shown by movements of the eyebrows and the upper lip.

The Facial Acting Coding System aims to focus on this commonality. However, they do not want it to be distributed for widespread use until they are satisfied that comprehensive training is done among clinicians in all major countries.

The goal is for this (or a tool like it) to gain universal acceptance and use.

You may not always be able to eliminate all of the discomfort your cognitively impaired patient seems to have. But mastering more subtle, and dementia-specific, assessment skills could start to produce better results in less time.

As long as so many physicians are afraid to prescribe sufficient doses of analgesics to dementia patients, it falls to nurses to use the “stepped treatment approach”.

This, as we mentioned in Part 1, would include medications as well as distraction, massage, music, positioning, and other modalities.

Whenever you have ideas on better pain-assessment tool, or effective pain-relieving measures, for mentally / emotionally impaired individuals, please consider sharing your data with COST at http://www.cost-td1005.net/ .

So good luck as you give it a try!






Little-Known Pain-Assessment Tricks for Dementia Patients – Part 1 of 2

Part 1 of 2

I wish she would just say “Ouch!”

So your dementia patient’s behavior is requiring a sitter. Are the behaviors coming from unmet physical or psychological needs, or physical illnesses like urinary tract infections? Or might they be in pain?

How can you assess the meaning behind the behavior of the cognitively impaired? Many clinicians do not realize that pain is the most common problem causing difficult behaviors in the cognitively impaired. Behavioral problems are also what most often lead to institutionalization of dementia patients.

Our planet contains at least 35 million people diagnosed with dementia – most of whom are over age 65. Approximately 50% of patients with dementia are continually suffering pain. And 60% – 80% of institutionalized dementia patients are said to be experiencing chronic pain.

There are four main types of dementia. They are: Alzheimer’s Disease (AD), vascular dementia (VaD), frontotemporal dementia (FTD), and Lewy body dementia – with AD being the most common type. Some also have a combination of AD and VaD (ADVaD).

As you would imagine, different processes in the brain can cause type-specific responses to pain and pain treatments because of the neuropathological changes in the brain.

prescription-pad-blank-6939498Too often providers mistakenly prescribe inappropriate treatment of behavior with antipsychotic medication instead of addressing the pain in these patients.

Surely, pain in dementia patients can be a confusing topic – and one that has not received enough attention.

Mental illnesses, such as depression and others, often go with dementia and tend to twist perceptions and reactions. Breakdown of language, causing unreported pain, often accompanies outward expressions of agitation, aggression, delusions, wandering, and resistance to care.

In fact, pain is often the greatest cause of behavioral problems in the cognitively impaired. This agitation and aggression can be enormously upsetting for both the patient and their family – and can result in falls.

Some dementia patients suffer severe pain because their brain pathology gives them a lower tolerance to opioids. To be on the safe side, physicians tend to prescribe about 1/3 the amount of opioids for their dementia patients as they do for non-dementia patients of the same age and health status.

 Clearly, better assessment tools need to be developed and implemented by well-trained clinicians. And, in the meantime, non-narcotic pain-relieving modalities need to be used more to alleviate some suffering.

The most effective treatment method found, so far, is the use of “stepped treatment approaches”. This would include medications as well as distraction, massage, music, positioning, and other modalities.

You already know the many ways that pain inhibits recovery from illness or surgery. So, the question that begs attention is: How can clinicians more accurately assess, treat, and evaluate pain in dementia patients? The current pain scale tools are not effective in most of these cases.

Part 2 of this 4 part series reveals clever assessment tactics and subtle clues to watch for to help you in your practice. So stay tuned!





Neonatal Nursing and Beyond

Save your back! Care for TINY patients! Of course that is not the main reason for going into neonatal nursing. But it is a great side-benefit.

It looks like the average salary, for a neonatal nurse, ranges from the $70K’s to $90K’s. Of course that depends on your education and experience, the size of your city and hospital, and other factors. There can sometimes be impressive sign-on bonuses offered.

But salary is also not the most important factor for nurses entering this subspecialty. Neonatal neonate-mediumnursing is the kind of job that nurses are drawn to by their hearts.

So, how does a nurse get into this arena?

Begin with your RN degree – usually a BSN is most accepted. Pass boards. Take a job in a hospital’s NICU to gain experience.

Some hospitals may require initial experience in pediatrics or newborn nursery with a future transfer to NICU.

Work your way up to Level III NICU to prepare you for earning your advanced degree(s) in this specialty.

If you really love this field, you may consider earning your certification. You could work your way to charge nurse, nurse manager, nurse educator, clinical nurse specialist, developmental care specialist. You may also want to earn your Master’s or Doctorate degree.

There are many pathways to consider once you have gotten some experience in the care of these tiny ones. Each subspecialty seems to also offer multiple sub-subspecialties.

The National Association of Neonatal Nurses (NANN) helps lay out the guidelines. They also offer a certification program in neonatal nursing care.

In what environments do neonatal nurses generally find themselves?

Most will work in a neonatal intensive care unit (NICU) – caring for between one to four patients.

Some may be part of a neonatal transport team, or work as a visiting home health nurse.

Neonatal nurses may also work on the extracorporeal membrane oxygenation (ECMO) team. They provide heart-lung bypass for certain critically ill infants.

What other roles might a neonatal nurse fill?

You could function as a stabilization nurse and attend high-risk deliveries. Your work might remain mostly within the NICU- working with unstable infants and educating parents and facilitating their bonding with their infants.

This is a rewarding specialty that will sometimes give you the thrill of a lifetime – and at other times, break your heart. You have to be tough – and tender. You have to work very well with your team. And you have to truly love babies and their families.

Only your heart knows whether this is the right career path for you.

So Cheers!

Drop a line and tell me your experiences and thoughts below.



Nursing Instructors Influence a Generation

????????????????????????????????????????????????????????????????Google says that the average salary for an assistant nurse educator/ professor is $78,242. But, as with any job, pay depends on the person’s level of experience, size of the city, reputation of the college, and in what part of the country they teach.

A side note is: educators who work only during the academic year are paid their annual salary over those nine months.

In what settings do nursing instructors work? Most nurse educators are employed by colleges or universities.

All nurses have a fairly good idea of what nursing instructors do for the students. But what are their behind-the-scenes duties and expectations? And what should a person know before considering such a venture?

  • Participate in nursing curriculum development and instructional progression.
  • Help in evaluating the program’s core curriculum, assess effectiveness of institution’s efforts, and prepare reports.
  • Coordinate plans and programs with instructors in other departments.
  • Support recruiting and participate in interviewing nurse educator candidates.
  • Play a part in your department’s textbook orders.
  • Serve on various institutional committees.
  • Assure QA for continued compliance with all governing entities.
  • Promote recruitment of students through methods set in place by college.
  • Become acquainted, and work well, with managers at clinical rotation sites.
  • Work overtime hours as needed.
  • Keep abreast of new developments in the nursing field and incorporate those into their lessons as authorized.

What are the minimum requirements to enter this field? Nurse instructors may teach in theteacher-apple-clip-art-books-20clipart-books_apple_pencil_school LVN program with a bachelor’s degree, two years nursing experience, and a valid nursing license. To teach in a BSN program, a minimum of MSN degree is usually required, but a BSN degree may sometimes be acceptable.

What are nurse educators’ hours? Besides the obvious work hours, most are expected to spend about 10 hours of office-time per week to complete their admin duties.

Is there much overtime involved? There are likely to be many opportunities to participate in professional seminars and meetings. These could take place outside of normal business hours.

How do nursing instructors train for their jobs? There are programs that offer a Masters of Science degree in Nursing and Health Care Education. The University of Phoenix is one college that offers this.

A Certified Nurse Educator (CNE) examination program has been developed and is offered through The National League for Nursing (NLN). It is optional, but it does demonstrate a nurse’s interest and expertise in nursing education.

What is the job outlook for nursing instructors in this country? The need is great, and the projection for increase in employment opportunities for all types of postsecondary teachers is from 2012-2022 is 19%.

Many toss out their opinions as to why there seems to be such a shortage of nursing instructors and why it is often very difficult for qualified, would-be, nursing students to be accepted into college programs.

But the bottom line is this: If you would like to see the nursing field flourish more than it is, consider becoming a nursing instructor. That is where you can have the greatest influence on the future of nursing.

The power is in your hands and in your heart.









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