Transcript: How to Make a Plan of Care as a New Nurse Practitioner

Liz Rohr:

Well, hey there. It's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn more faster so you can take the best care of your patients. So I apologize, I've got a little bit of laryngitis today, but moving on, I want to take a pause on the lab interpretation series today to address an issue that's come up in the last week with a lot of new grads I've talked to, and that's the issue and the question of coming up with a plan of care. So whether or not you feel super strong with your differential diagnosis, or if you're feeling a little bit shaky or very shaky, that's totally okay. Making the leap between the differentials and the plan of care can kind of feel like you're coming up drawing a blank.

So I wanted to tell you today about the steps that I take and that I recommend you do to help you feel confident in your decisions, and also make sure that you're not missing anything. I'm also going to add in two kind of real world tips about making plans of care. And you may find that you need to go through this yourself and come to your own conclusions. But if I can help save you a little bit of frustration, that would be awesome.

So there's five steps here. So step number one is coming up with your red flag diagnoses. And so for red flags, what I mean are the differential diagnoses that if you miss them, it would be really bad. So those are things that are life-threatening and could kill you. So it's really important to come up with those differentials. What are those possibilities? And work on ruling them out.

And so kind of a side note to this number one is that if you don't have ready access to the tools that you need, or the tests that you need to do to rule them out, like an abdominal CT to rule out appendicitis, they need to go to the ER. That is super easy. So step one, differential diagnosis, is it life threatening? Do you have the tools to rule it out? Yes. Then you do those. And if not, then you send them out.

So step number two, is the best way that I recommend kind of coming up with your plan of care, the place to start is an algorithm. And this comes back to your resources. So I have two resources that I super love, and these are in the resource guide, if you haven't gotten a copy yet. And I don't get paid to tell you this, I just super love them.

So number one is Up-to-Date, I'm such an Up-to-Date junkie. And number two is Symptom to Diagnosis. It's a really awesome book that literally just takes a symptom and brings you down the path to diagnosis. So a note about the algorithm kind of workup that you're going to choose, I posted this, a little note about this on Instagram and Facebook, if you caught it already. But if not, there's a common medical adage saying that goes, if you hear hoof beats, think horses and not zebras. And so you want to start with common things that appear commonly. Additionally, you also want to think about the pertinent positives and negatives. So when I was in school, if you had a symptom like a cough, you made a table of the pertinent positive symptoms and the pertinent negatives for each differential diagnosis, and the one with the most pertinent positives was kind of more the path that you would lead down.

So yeah. So step number one is red flags. Sending to the ER, if you need to. Step number two is choosing the algorithm from a resource that you really love and trust. Acknowledging that common things appear commonly and trying not to chase those rare, zebra, rare diagnoses, although it's tempting and super fun. Number three, and this can be a little bit scary, but you kind of just have to put a stake in the ground and just choose. You have to pick one diagnosis that you're like, you know what? I think that this is the diagnosis. So if I can give an example of this. So if you have a kid with sore throat, he's 22, he has a fever of a 100.7. He's got tender cervical lymphadenopathy. He's got a little bit over a runny nose. He doesn't have a cough. He doesn't have a rash. He doesn't have any exudate on his tonsils when you do an exam. He doesn't have any ear symptoms. Nausea, vomiting, diarrhea, everything else is basically normal.

So if you're thinking about this kid, the red flag diagnoses that I would choose to investigate and make sure that it was not, number one is strep pharyngitis, because that would be pretty bad if you miss that. Number two is mono. So mono is a virus and will self resolve, but if somebody didn't know they had mono and then they got a spleen rupture, that would be pretty bad. And so the third one is a peritonsillar abscess. And so if you haven't heard of this, I would definitely Google it or look through your resources to learn a little bit more about it. But that's an abscess that goes around your tonsils. And that tends to have a high fever, severe neck pain, and can have a deviation of your uvula. So for him, those are the red flags.

The algorithm, you're kind of going to consult your resource of how to work those up and how to rule out those red flags. And the step number three is you kind of just have your stake in the ground. And so I don't know if you're familiar with the CENTOR criteria, C-E-N-T-O-R. I can put a link below this video to reference it if you haven't seen it already, but that has to do with strep pharyngitis. And the criteria that is suggestive of a strep pharyngitis, whether you can treat them, whether you should do a throat culture, or whether or not they probably don't have it. So for him, and there's either four or five criteria, depending on which tool you're using and I'm referencing the four step tool here.

But if he has a fever, tender cervical lymphadenopathy, no cough, and tonsillar exudate, that's a four out of four and then you treat them. If they have a three to four, you can either consider treating them or sending out a throat culture. And then if it's two or less, theoretically, you cannot do a throat culture, but I've seen people do throat cultures based on kind of a hunch. And that's another discussion for another time. But so for step number three, you're going to commit, you know what? I think this kid has strep. So you're going to put your stake in the ground and you're going to treat them, treat him and educate him based on that diagnosis. And so you're going to review, I'm going to give you penicillin twice a day for 10 days. Take it the whole time, even if you're feeling better. Drink plenty of water, take Tylenol and Motrin if you need to. Salt water gargles. Things I should probably be doing right now.

And then if you're not getting better ... You should be getting better in the next 24 hours. And if you're getting significantly worse, you have high fever, shaking, chills, mucal rigidity, you should probably be seen in the ER, because there's a chance that you could have a peritonsillar abscess. Otherwise, he should be on a trajectory of getting better and better in the next week or so. And so if he's not, then he should come back. So those are the things you want to counsel the patients on. That's step number three, deciding the diagnosis and then counseling them appropriately. Reviewing those alarm signs and symptoms and when he should come back.

So step number four ... Sorry about that. So I actually just kind of combined step three and step four. So step three is kind of putting your stake in the ground. And step number four is the education and the alarm signs and symptoms. So the alarm signs and symptoms, the education of when they should come back, if they're not feeling better, just being really clear about that, because that's really going to protect you in case when you said that this was strep and it's not actually strep, that he'll actually come back and seek further care and know to do that. And then step number five is say, like a week later, you get a phone call or you see the patient again in the clinic that you know what, I'm feeling a lot better, but I'm still not totally better and I have this new symptom. You're going to go and take yourself all the way back to the algorithm that you saw before about working up a sore throat and kind of take the next best option, making sure again, that it's not a red flag and then moving onto the next most common diagnosis and going from there.

So those are all the five steps. So a disclaimer that I want to make here is that, so I had a patient in my last clinic who came in for the first time with a sore throat, was treated for a viral pharyngitis suspected. And then she kind of kept coming back as she was directed. She either came back two or three more times after that. But I think on the second time she was diagnosed maybe with allergic rhinitis, a postnasal drip sore throat versus a GERD, a reflux sore throat.

But at the same time, additionally, she was sent to ear, nose, and throat because based on her pertinent positives and negatives, they weren't super clear. It wasn't like, absolutely this is reflux related. Absolutely, this is allergy related. So like, you know what, let's just see ENT, the ear, nose and throat specialist and get another set of eyes on this. And you what? It ended up that that patient had cancer, had throat cancer. So that's something to think about for yourself. And it's not to scare you. I should back up and add the disclaimer that I used to be an oncology nurse. So I think that all patients have cancer until proven otherwise. But so yeah, it's not to scare you, but it's something to keep in mind that it's a fluid process of the red flags, matching things up based on the pertinent positives and negatives and the most common options, but listening to your gut feeling of this doesn't really make sense and let's just make sure that she doesn't have anything else going on or he doesn't have anything else going on.

So the two real world tips that I want to make about coming up with a plan of care. Number one is that this happens to me quite a bit. And I don't know, maybe it's my clinic type or setting or whatever, but patients will come in establishing care for the first time, haven't seen a doctor in years and years. They've had a 10 year old problem that they come in with and they expect that I'm going to be able to fix it for them right then. So that is not realistic. So just, this is just a take home for you, is that if there's a chronic problem that's going on for a very long time and it's never had any workup or any treatment, that's not realistic for ... and don't put that pressure on yourself to try to fix it in that visit.

And also just setting up those expectations for that patient of, you know what? This has been going on for a long time. I want to help you with this problem. I don't know if I'm going to be able to fix it today, but here are the steps that we're going to take. And here's kind of what to expect. This comes from your algorithm. You don't necessarily have to know this by experience. Once you get more experience, you'll be able to see that. But I definitely like to prepare patients of like going back to the kid with the strep is that, or the sore throat, I'm like, my approach is that, you know what? Most likely you have a bacterial throat infection. There's a possibility it could be something else.

And depending on how nervous they seem or how health literate they are in terms of their understanding of health things, I don't want to overwhelm them, but sometimes I'll prepare them of like, oh, you might have mono, you might have this, blah, blah, blah, blah, blah. So that they know, please come back in the next week, it may be this and we'll kind of do this. So same thing with those 10 year chronic problems, do your best to come up with a plan based on that algorithm, based on the most likely pertinent positive and negatives, most likely diagnosis based on the pertinent positives and negatives, and then just take it from there.

And the second real world thing I want to say is that it commonly happens with the kinds of patients that will come in with a 10 year problem after not seeing a doctor for 10 years, is that they will have 17 problems that they want you to fix today. And you know what? They do want those problems addressed and I want to address those problems for them, but that is just not realistic. And it's not realistic for a number of reasons. So number one, so it's not someone that comes in with five problems. They want all those five problems solved, right? But patients don't typically understand the workup and the treatment that is involved in taking care of those problems. And a lot of the times, especially when I was brand new, I would do this all the time and I'd be like, okay, we're going to send you to three specialists. We're going to take these medications. Don't do that. I mean, you can. I have patients where I say, I'm going to overwhelm you if we address all of these things at once. And they're like, no, no, no, I just want to do it.

So that's really a discussion. But number one, it's not really good for them because you're not actually helping solve those five problems. Because they're going to get overwhelmed and they're not necessarily going to be able to handle them all. And number two, it's just not realistic for yourself because I'm a super sucker and I try to do that for them. But also it doesn't benefit them, but it doesn't benefit me as a clinician. It doesn't necessarily benefit you as a clinician and that's not selfish because that is helping to take really good care of not only your patients, but yourself. And if you don't take good care of yourself, then you can't be an NP. And then you're not helping anybody, right? You're not helping yourself. You're not helping your patients.

So it's okay to protect yourself. So what I say to patients is, you know what, you have five problems. I want to make sure that we're really addressing them thoroughly, we're not missing anything, and that you're not going to get overwhelmed and that neither of us was going to get overwhelmed. And that's going to actually solve the problems for you. So what is the most important thing that you want to fix today? And patients don't always necessarily appreciate acuity. So somebody might be fluid overloaded and be in active heart failure and they probably need some Lasix or treatment like that. So they're short of breath, but then they also have toe pain. And they might decide that the toe pain is more bothersome than the shortness of breath. But you have permission to triage that yourself and decide, you know what? I'm going to deal with the shortness of breath and the toe pain or taking it from there.

So I'd love to hear from you. Are there any strategies that I mentioned that you're using or steps that you're using? Or is there something that you're doing that's separate from that, that's working really well for you? I'd love to hear it. Because I learn from you, but also the other nurse practitioners that watch these videos also take a lot out of that. So definitely leave me a comment below. Did you like this video? If so, hit like and subscribe, and share with your NP friends so that we can reach as many new grads as possible to help ease their transition to practice as well.

And so I mentioned that in this video, don't mean to be a broken record, but the ultimate resource guide is free available to you and it's my favorite resources that I use every day. So just head on over to realworldnp.com, sign up for the email list. You'll get it straight to your inbox. You'll also get the weekly emails from me and you'll get more tips, patient stories, and other bonus content that I just don't share anywhere else. YouTube, Instagram, Facebook, website, nowhere else. So sign-on up. And I hear that they're pretty awesome. Thank you so much for watching. Hang in there and I'll see you next time.