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    L Jane Acree

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.








Wilderness Nursing

lady in front of mountainsDo you have an adventurous spirit? Are you a little wild at heart? Combine those traits with your nursing skills and you will discover a wilderness nurse.

Consider the conquering spirit that loves to encounter water, mountains, snow, waterfalls, sky, wild animals, desert, or any other type of environment. And there you will also, unfortunately, find people who suffer trauma or illness.

And you can be the one to rescue them. Think about it. You could apply your professional experience to wilderness medical emergencies. Enjoy the wild and help others at the same time.

If you are a nurse who also loves – say – mountain climbing, you could train to lead a group on a climb and double as a nurse giving wilderness emergency pre-hospital care as needed.

You will obviously need to gain wilderness and leadership skills, along with the ability to work with a range of people and personalities. A background in ER, critical care, and pre-hospital emergency nursing is clearly needed.

This type of work calls for staying in strong physical condition. Weather, terrain and the characteristics of the individuals and their injuries could often call for physically demanding efforts on your part.

What certifications should you earn? Check out the Wilderness Medical Society. Certifications such as WALS, WEMT, CEN, and CPEN. These are all helpful in making you as qualified as possible to render life-saving aid in wilderness environments.mountain climbing

Earning your FNP will help you be more competitive in that job field, and also enable you to write prescriptions.

That sounds like a lot of training. But, you will progress. Starting with your RN degree, begin working in a high-volume ER in a major city and learn from a wide variety of experiences.

Then after 2-3 years in the ER, take a pre-hospital paramedic course and work a job in a rural/remote area. You will gain great experience treating a wide variety of conditions.

Go on different kinds of expeditions and observe the skills and confidence required for back country medicine. Note how care is provided in places that are not clean, well-lit, and with only the equipment that can be carried on your back.

Attend nature-based continued education experiences in the wilderness with doctors, EMT’s, and other nurses whenever you can. There are adrenalin-pumping CME adventures being offered WORLDWIDE.

There are many classes being offered for Wilderness Medical Training. They are probably all exciting and educational. BUT, investigate. Always be sure you spend your time and money only on classes that are accredited!

Since most expeditions will not hire a medic just because they are a medic. It is necessary to also possess other needed skills. One choice is to be the team’s photographer and medic or climbing guide and medic, etc.

If you want to take a ONE-YEAR Wilderness Certification Program that says they teach you all aspects of wilderness survival, see: http://www.wildernesscollege.com/wilderness-certification.html?gclid=COSJjua6qMQCFUMvgQodZJ0ADA

Is there good money in this? That depends. Some expeditions may pay, but many expeditions would expect you to join the team as a volunteer. Your expenses might be partially or completely paid.

However, wilderness medic instructors are paid.

A more tame variety of wilderness nursing would be to work in a Wilderness Treatment Center. These are 12-step inpatient chemical dependency addiction treatment facilities in remote wilderness settings.

So there is no excuse for being bored in your job. Adventure awaits!

Be sure to look at these awesome references below and check out the books suggested at the side bars of this site.










What is Outpost Nursing?

inuitladyOutpost nursing is pretty much an unfamiliar term in the US. However, Canada has about 800 outpost nurses stationed throughout the more northern regions of their country. And US travel nurses sometimes take 13 week assignments there as well.

Outpost nurses are actually the primary care health providers in remote, undeserved communities of which many have only fly-in access.

Outpost nurses say their role is what community nursing is all about – using what you have, in cooperation with your local people, and getting them to help you make things happen. And they will if they’re given the chance.

Doctors may visit only every one to six weeks but are available by phone. So outpost nurses must be able to work very independently.

Residents of the remote northern communities, where outpost nurses practice, are said to experience the poorest health status of all Canadians. This is partly related to their isolation and lack of connection with better ways of living. So these nurses are literally their life-line.

Primary health care know-how is an expectation of outpost nurses. This role integrates the concepts of disease prevention, health promotion, population health and community development. Responsive relationships, and trust, with community members increase adherence to healthy choices.

Some say that ideally this would be a nurse practitioner role. However outpost trained nurses, with ER backgrounds, are the ones who are (very capably) filling most of these positions.

Outpost nurses must be independent by nature. They must have assertive personalities and strong assessment and teaching skills.

They must triage, deliver babies, prescribe drugs (per standing orders), perform dressingIgloolik changes, remove staples/sutures, collect samples, take x-rays, run and develop tests, and interpret results – and even perform some small surgical procedures.

Outpost nurses are community health nurses and usually the only health care source in the entire village. Besides physical care, they provide education, screening, immunizations.

She might be a public health nurse this morning, an ER nurse this afternoon, and a flight nurse in the middle of the night on some days. She is always on call. Her position, and her love and devotion to her community, make her a powerful advocate.

Due to the extreme level of responsibility, at least two years of hospital experience is generally mandatory. Of great help is having extra training and certification through a northern clinical program or outpost nursing program.

One to four nurses may communities of from 300 to 2000 inhabitants. They may also drive from one community to the next as part of their responsibilities. They must also be very versatile in diverse situations.

You must know your limitations and be able to deal with the isolation and inconveniences of living in a tiny village.

What does it pay? I found three job postings offering 123600$ (Canadian dollars) for a full time outpost nurse. Currently one Canadian dollar equals $0.78 USD.

You may want to check out the Dalhousie Outpost Nursing Program. It is designed to prepare RN’s for this work.

You can also find nurse forums discussing this specialty field. If you have an independent spirit, and you don’t mind the cold, check out some of the following resources and get more information.

As always, Cheers!






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