Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.
Tips for New Grad Nurses on Resumes, Applications, and Interviews
This episode covers the essential aspects of landing a job and gives practical tips for new grad nurse on resumes, applications, and interviews. All three of the hosts have experience interviewing new graduates and we give you our insider tips on the process.
Perfect, no typographical errors
Don’t put all of your clinical experience
Put things that are relevant to this job
Put people other than your clinical instructors; nurses on the unit, MD’s, manager
Get a team of cheerleaders – people who will vouch for you
Networking begins in nursing school
Make a good impression EVERYWHERE
Don’t think only clinical people can write resumes
So, you’re getting ready to graduate nursing school and are looking around for some free and paid NCLEX® questionnaires. Let’s be real, everyone would like to try to get as many practice test questions as possible, which typically consists of checking out not one, but multiple free and paid NCLEX® question banks to maximize your dollar and time.
What to look for in NCLEX® Questionnaires
Getting access to NCLEX® questions is helpful, but there’s more to it than that. You don’t just want to know the right answer, you want to know the rationale so you can learn why that’s the right answer. Even better, if they can tell you the level of difficulty and how it stacks up against the rest of their question bank, that’s amazing.
Remember, the NCLEX® isn’t a normal test… it’s a computerized adaptive test (CAT). What does that mean? Here’s a great explanation from the National Council of State Boards of Nursing (the people who write the test!) about what a CAT really means. So, just getting a bank of multiple choice questions isn’t going to cut it. You need to know not only the right answer, but the rationale and how difficult the question is, as well as questions with alternate formats. You also don’t want to get the same questions over and over, so you need a large bank of question (1,500+).
What’s best is if you can find a question bank that also has a content review, so if you got a question wrong and need more information than the rationale supplies, you’ve got resources to dive deeper into. More things to look for are programs actually written by nurses, ones that provide the ability for you to give feedback on a question, as well as the ability to to purchase more. The absolute best if if you can find one that has a money-back guarantee if you end up not passing the NCLEX®.
If you want a comprehensive, quality NCLEX® questions and review, you are looking at dropping at least a few hundred dollars. It’s expensive, but not passing the first time around can cost on average $10K – $20K in lost wages, fees, and study costs.
Look for the following aspects of quality NCLEX® questionnaires:
A large bank of questions
At least over 1,500 but you may want to look for one with substantially more because if you’re diligent in taking practice questions, you’ll go through 1,500 faster than you realize
Questions with alternate formats
All of the possible alternate format question that may appear on the exam include select all that apply, hot spots, fill in the blanks, ordered response, audio options, graphic options
Difficulty level of the question
Nurses actually writing the content/questions
Able to use features on mobile
This would be a bonus, not a requirement – in my opinion
The ability to provide feedback
This would be a bonus, not a requirement
The ability to take a simulation exam
This wouldn’t provide the answers immediately, but attempt to simulate the NCLEX® to assess your level of readiness
Test.com is simply 23 free NCLEX® prep questions with a buy-up option to their course. You don’t have to register to get the correct answers, but it’s just a few. The buy up is to their review with 800 questions, which is written by nurses, contains a money-back guarantee, mobile-enabled, a create-your-own flashcards, as well as simulation exam capabilities. It’s probably one of the cheapest, if not the cheapest programs out there.
I am a big fan of the way Khan Academy teaches. They utilize short videos that are packed with high-value information. Also, they’re free! The NCLEX® prep section has over 600 YouTube videos that are around 10 minutes each. They are mostly taught by physicians, however, because they’re going into the pathophysiology behind things and not actual nursing care. Essentially, you’re missing a massive part of the test content. While they do have some NCLEX® prep questions, it’s only 86 total. You do not have to register to get access to them.
My thoughts – this would be a good resource for reviewing pathophysiological content that is hard to grasp and just to have access to 86 free questions… but it should by no means be your only review. Since their focus is on patho, there are no nursing topics which comprise major aspects of the exam. I’d do the 86 questions, then use a handful of videos if needed.
Nurse Labs is arguably the largest database of free NCLEX® prep questions at over 3,500. You don’t have to give them your email, they’re broken up into different categories, and they have different modes you can take them in (exam, practice, text). They have some free study guides which accompany content. You are told which answers are correct and it seems like (sorry I didn’t take all 3,500+ questions to know for sure!) there’s a rationale most of the time, but not always. The way it is organized isn’t the best, but what can you expect when you’re getting a ton of free questions?
My thoughts – this is a ton of free NCLEX® prep questions. I feel like the way the site is organized, it’s hard to keep yourself organized. As far as I could tell, there were no alternative format questions or an option to purchase a full review. While there is some content review, you do have to look for it. Also, one of my nurse red-flags went up when looking into the site… their “about” page is pretty non-descript. I cannot tell who writes these questions or who owns this company, which is a little concerning to me. The way I would approach this is I would purchase an NCLEX® review and use that as my primary question bank, then I would only use the Nurse Labs one if I went through all of those questions.
If you do all three of these, you’ll have 3,609 free NCLEX® practice questions.
Please note, UWorld, Hurst, Kaplan and NRSNG all offer a free set of sample questions – but they are all discussed in the paid section!
Paid NCLEX® Questionnaires
Kaplan is quite well know. They have different options for reviews like just an adaptive practice test (cheapest), a self-paced online course, a live online course, and an in-person course.
They have a 3,400 question bank which includes alternate format items, content review, workbook, simulation NCLEX®, as well as a money-back guarantee. They teach a “decision tree” which helps you think through each question in a systematic format. Their price points range from $129 – $500. Some schools will include this review within your tuition. You can also simply purchase their question bank.
NRSNG Academyhas an adaptive NCLEX® simulator (“SIMCLEX”), a question bank of 3,500 questions with the ability to provide feedback and see the difficulty rank, 500+ flashcards, image and audio database, a test-taking course, and 10 concise content courses, is entirely available on mobile, a private Facebook group for support, and lifetime access to content after the subscription is complete (9 months). Their pricing structure is a bit different, in that you pay a monthly fee for 9 months. They also have a 200% money-back guarantee, so if you don’t pass the NCLEX® while using their resources, they’ll refund your money and pay you that same amount as well.
What is cool about this is you can get it when you start nursing school, and it will be valuable throughout school, during the NCLEX®, and after. Also, if you only need it for a few months, it’s significantly cheaper than the other NCLEX® review options. They also have the option of simply purchasing their question bank. Right now you can get a 7 day trial for only $1.
Hurst has 3 different options of an in-person review, a live online review, or an online course. They have a question bank of 1,000 questions, a workbook, test simulator, 4 125-question prep tests, an online coach, and a money-back guarantee. If you buy the in-person review, you are able to attend as many in-person events as you’d like.
Board Vitalshas a question bank of 4,100 questions with rationales and alternative formats, an exam blueprint, computer adaptive exams,
Interestingly enough, with each purchase they donate a vaccination to a child in need. Two of their 4 plans have a money-back guarantee. I personally know people who have tried all of the other products mentioned, but don’t know anyone who has used this product.
NCSBN (National Counsel of State Boards of Nursing)
This is an NCLEX® prep program from the same company who actually write the test. Their question bank has 3,100 questions, a content review, quizzes, capable of being used on mobile, and an Ask the Instructor feature. I somewhat stumbled upon this during researching these options, so I’m not very familiar with it or know anyone who has used it. But, given that it comes from the same company that writes the test, I’d say it’s safe to assume it’s quite reputable. They also have study plans, which are nice to have structured for you.
UWorld is another popular choice. While it’s test bank is 1,950 questions, they also have two 75-question self-assessments, are mobile-ready, and I’ve heard that their rationales are superior to some others NCLEX® reviews. I actually did a more comprehensive review of this system on the blog already! Click here to check it out. I think this is a good option or someone who just needs test question practice and not content review, because you will not get that with UWorld. Their pricing structure is different than some of the others as well, since they go by month rather than one large purchase.
Whatever program you pick, it’s important to do what’s best for you, your learning style and needs, and budget. Some people just want a content review, some just want practice questions, some want both. There’s no shame in your NCLEX® prep game, do what you need to do to pass!
Thank you to AORN for partnering with us for this post.
So you’re a nurse or in nursing school, and you think you want to work in the operating room… or endoscopy… or the postanesthesia care unit… or interventional radiology. But, what are the important things to know before getting into this specialized field within nursing? What do perioperative nurses do, exactly?
What do perioperative nurses do?
I had the opportunity to interview Amber Wood, MSN RN CNOR CIC FAPIC, who is a Senior Perioperative Practice Specialist for the Association of PeriOperative Nurses (AORN) and previously an operating room (OR) nurse at Children’s Medical Center in Dallas, TX. She shares what it’s really like to be a perioperative nurse.
Options for a new graduate interested in perioperative nursing
Working as a critical care nurse, I have to admit… I was a bit ignorant to all of the perioperative options. Amber informed me that the options include, not only your typical preoperative (pre-op), intraoperative (operating room, or OR nurse), and postanesthesia care unit (PACU), but also procedural areas like endoscopy, cath lab, and interventional radiology.
Nurses can further specialize in the OR. Amber noted that, “you can specialize in the OR by service line. For instance, things cardiac surgery, neurosurgery, orthopedics are all specialties… all of which are are challenging in their own way.”
Naturally, your options are dictated by the size of the institution. If it’s a large hospital or a teaching facility, you’ll have more options. If you’re in a smaller rural hospital, you won’t have as many.
When thinking about OR subspecialties like cardiac surgery, orthopedics or neurosurgery, there’s more to consider than the type of population you’ll be serving. You really have to also consider the team you’ll be working with and the flow of the day. Maybe you love orthopedics, but you don’t really mesh into that group of people well… or maybe you like lots of volume and patient turnover rather than longer cases with sicker patients.
What’s most rewarding about perioperative nursing?
When I asked Amber about the most rewarding aspect (in her opinion) of the perioperative nursing specialty, she responded by saying, “it’s definitely being able to advocate for patients when they are most vulnerable. Their family isn’t there and they can’t advocate for themselves.”
In the perioperative world, patients are sedated for their procedure. Their family members cannot come back and hold their hand mid-procedure and ask questions. The responsibility to comfort, encourage, and advocate falls upon the nurse.
What’s most challenging about perioperative nursing?
When discussing challenges within this specialty, Amber mentioned how different teamwork looks in the perioperative world.
When I think about teamwork while providing patient care, I connect it to my experience. For me, I’m used to being on a floor or critical care unit in which I call a physician or healthcare team member as needed to discuss issues. However, this is not the case in perioperative nursing.
Teamwork is elbow-to-elbow. Instead of paging a physician with a concern and waiting for a reply, the physician is right there. While that sounds easy and wonderful, some are not used to it.
Amber stated, it’s “different from working in other areas because everyone on the team is working at the same time, rather than coming in and out. This real-time teamwork and collaboration can be challenging for some. You really have to function within that team and play your roles at the time. This means you have to know and understand everyone else’s roles as well. This can be particularly challenging if you enjoy working independently.”
Amber went over a typical day for an OR nurse with me. One of the first things she mentioned was that the way your day will look really depends the shift/time of day and if you’re scrubbing in or circulating.
Amber noted that, “the scrub nurse is more focused on instrumentation, planning, and coordination of that while the circulating nurse would be more focused on positioning, equipment, medications, and ensure any issues with implants, tissues, and/or specimens that are needed is addressed.” Also, depending on your facility, you may or may not be working with surgical technologists.
A typical day as an OR nurse
Receive your assignment for the day
Go over the surgery schedule: the charge nurse will communicate any special needs, requests, or changes to the plan that have arisen
Begin preparing the operating room
You typically have around 30 minutes before you must get a patient in a room
Begin planning the day, getting special equipment ready for surgery
Ensure rooms are cleaned and ready to go
Check important equipment (like suction!)
Ensure you have the appropriate instruments for the day
Head to pre-op holding to get your patient
Receive report from the preoperative nurse, ensure you’ve got consent, and begin building rapport with the patient – they’re about to put their life in your hands
Transport to the operating room
Assist as needed with anesthesia
Begin positioning, skin prep, establishing a sterile field, and monitoring
If everyone else is scrubbed in, you’re grabbing anything that’s needed
If it’s a surgery requiring multiple surgeons, you’re coordinating that
Once surgery is complete, call report to their destination
Get them ready to go and transport
Clean the room and get ready to start all over again!
Amber says it can sound a lot like a traffic controller because so much is going on at once – and lives are at stake!
Recommendations for people interested in perioperative nursing
Perioperative nursing is a highly specialized field, therefore you really want to ensure it is where you want to be.
Amber recommends getting as much clinical experience in perioperative areas as possible during nursing school. Amber, like myself, completed an externship between her junior and senior years of nursing school and spent time in the OR. She said this further solidified her interest in working in a pediatric OR.
But if you must work in another area of the hospital because you can’t get into the perioperative areas, try to stick to surgical areas within the service line you’re interested in.
learn the latest in best practice with over 200 continuing education units available
on-demand streaming service for sessions you couldn’t get to
session in the exhibit hall)
network with perioperative nurses all over the country
take advantage of the largest surgical trade show in the country by visiting the exhibit hall
feel energized from all of the fun events and passionate nurses.
A special opportunity for students
AORN is excited to offer nursing students a complimentary* registration to Global Surgical Conference & Expo 2018!
Students from local nursing programs can come for the entire week, or attend AORN Student Nurses Day on Tuesday, March 27th for a special one-day student program. This conference offers nursing students a unique opportunity to learn more about perioperative nursing and take advantage of superior education developed by leading industry experts.
During AORN Student Nurses Day, AORN will offer special activities. In the morning, students will have the opportunity to practice hands-on activities (like proper hand hygiene, gowning and gloving, surgical prepping, and positioning). In the afternoon, AORN will host an exhibit floor session to explore the complexity of surgical products and equipment. Students will be able to interact with vendors, including multiple nurse recruiter booths.Plus, student nurses who attend will receive a free one-year m
If you are at all interested in becoming a perioperative nurse, you must attend this conference! We’ve partnered with AORN to make that a little easier for you.
AORN has generously donated a 5-night hotel stay to one lucky student to enable them to come to the conference! As mentioned, entry for students is complimentary and with this 5-day hotel stay, you’ll be able to reduce the cost significantly!
Complete the entry form below for a chance to win.
You’re going to graduate nursing school soon and have started applying at different facilities and finally gotten some interviews. You’ve read you’re supposed to practice questions beforehand, but what questions are those exactly… and why is this necessary? You’d think you’ll be able to recall the various patient scenarios mid-interview, but it’s harder than you’d think. Eventually, your clinicals blend together and you forget some things. Now you’re in a high-pressure situation and it’s even more difficult to recall. By going over questions beforehand, you can get these scenarios fresh in your mind so you can recall them confidently and promptly.
So, let’s go over a list of sample questions for nurse job interviews.
Sample questions for nurse job interviews
Jot down some notes, think about specific patient situations, and have answers ready for the follow questions.
Why do you want to work here?
Why are you interested in this specific unit?
If it’s a cardiac unit, mention cardiac-specific things
If it’s a critical care unit, talk about things specific to that unit (ventilators, vasoactive medications, complex patients)
Why do you want to be a nurse? // What got you interested in nursing?
Tell me about your greatest strengths // what do you bring to the team?
Tell me about your biggest weaknesses // where do you see yourself requiring the most improvement?
Have you ever had to have a difficult conversation (tell them they’re wrong, correct them, etc) with a colleague? How did that go?
Tell me about a time in which you had to prioritize your time quickly, how did that go? Would you change how you handled it looking back?
What would your nursing professors // clinical instructors // classmates say about you?
Tell me about a time in which you had to do service recovery; how did that go?
Tell me about a time you made a mistake; what did you do to handle it?
Tell me about a time in which you had to advocate for a patient how did that go?
Have you ever observed someone else do something incorrectly? How did you handle that or react?
Tell me about the most memorable patient you’ve cared for and why they stick out in your mind.
Have you ever had an conflict with a peer/colleague, how did you handle that?
What are your short-term goals (within the next year)?
What are your long-term goals (in the next 5 years)?
Is there anything that would impend your ability to meet the job requirements?
Questions to ask them!
At the end of every interview, the interviewee will ask you if you have any questions. It is really important that you do this because you are a valuable nursing commodity – this is not a one-way interaction of auditioning for a role you desperately need. You want to see if this hospital is a good fit for you as well. This also makes you look more confident, as you are trying to see not only what you can offer them, but what they can offer you as well.
If these things are not already addressed, I encourage you to ask some of the following questions.
What is the current nurse:patient ratio? Has that changed recently?
What is the current turnover rate in this hospital as a whole and this specific unit? Has that changed recently?
Do you have a clinical ladder program?
*You should know if you’re applying to a Magnet Facility – if they already are one, ask when they’re up for redesingation and how long they’ve had this designation. If they are not, ask if they are planning on pursuing it in the future.
What are the incentives for a specality certification (increased pay, paying for the exam, etc.)
What is the culture of safety like on your unit?
Do you have a rapid response team?
Which computer charting system do you use?
Do you have Shared Governance set up; are people engaged with it?
How often is overtime and/or call time required?
Last question – always ask this! Do you have any reservations about me for this specific job?
This gives you the opportunity to address any of them and leave on a positive note
Please don’t use the initial interview to inquire about vacation time. It doesn’t look so hot. My advice is to ask about this if you are given a second interview and are considering multiple offers. I would not start off asking about vacation because that makes people think not working is your priority.
Things to not do
Don’t make the mistake of not practicing questions. It makes the intense Q&A of an interview go much smoother, especially if you’ve have limited clinical experiences to pull from. Take some time to refresh your memory and write them down if needed.
When describing experiences, don’t cut down other nurses to make yourself look good. It doesn’t work, you just end up looking like someone who has to put down others to elevate yourself…. Not a good look.
Don’t BS. Nurses are good at reading people and can typically tell when someone is making up an answer just to get through it. If you don’t know something, admit it, but counteract that with an opportunity to learn, a similar experience, or something you observed but really spoke to you.
Don’t refer to the same scenario over and over again. This is why practicing is so helpful because it brings various situations back to the forefront of your mind.
Pharmacology is challenging in nursing school, but it doesn’t have to destroy your life, soul, and all that you hold dear. If you take a few steps in organizing yourself before you tackle this class, it will make it easier to learn and recall later down the line.
Pharmacology tips – just for nursing students
The way nursing school approaches teaching pharmacology varies widely, but the subject matter remains the same. There are different pieces of information to know; some require straight memorization and repetition (dosages, names, antidotes), while others require some deeper understanding (like the mechanism of action, applying it to a clinical situation).
Know that while you’re starting to learn pharmacology, it’s not one method that works for all aspects of this course. One must leverage both memorization and deep thinking to fully comprehend all that encompasses medications. You can’t just take one study tactic and think you can use that to understand each aspect. The information is just different. Also, what further complicates things is that different professors teach this process different ways. Therefore, take some time to develop a routine that works for you and carry this method across different courses.
Whatever it takes, learn the mechanism of action inside and out. If how your professor has explained it doesn’t click, find some good videos, podcasts, or other explanations. Understanding this is helps you to predict side effects, adverse reactions, antidotes, and more. If you understand the mechanism of action, you have a solid understanding of that class of medications, and be able to troubleshoot questions easier.
Here’s an example of a great, free YouTube video of the mechanism of action behind NSAIDs.
Once you think you get it, try to explain it to someone else. If you don’t have someone to explain it to, explain it to yourself on your phone and listen back to it to see if it makes sense.
Memorize with intention
There is no short cut around a few things like prefixes, suffixes, generic and trade names, and dosages. You can create flashcards with pen and index cards, color-coding along the way… or, you can download an app. The wonderful things about apps are that you’re saving paper, can change them easily, organize into categories, and use them on the go.
Some examples of (free and not) apps you can get to create your own and use on the go are:
Whichever method, devote time to memorizing these things and doing flashcard drills. While you’re memorizing, it can be helpful to make up ridiculous things to help jog your memory. For example, beta blockers are funny so they always make me LOL, or ARB’s are what pirates use for their hypertension because they make them go arrrrrr(b)ggg, or lisinopril has a license to always throw an ACE (inhibitor) down in cards … you get the picture! The more ridiculous, the better. I found that if I could connect something to my favorite books/TV shows/movies, I remembered it better.
Check out the MedMaster podcast on NRSNG – it’s a helpful way to reiterate topics on the go.
Don’t just try to cram it all the night before – that’s too much to retain at once. If you know you have a med quiz in 7 days, use today to create your flashcards and your first time going over the mechanism of action. Schedule yourself for one focused hour tomorrow; part of the time diving into the mechanism of action over again, take a 5 minute break, and then spend the rest of the time drilling cards.
During downtime throughout the day (on the bus, in the elevator, waiting for your doctor’s appointment, whatever) go through some more cards. Bonus if they’re on your phone and you don’t have to remember to bring them everywhere.
If you can devote a specific amount of time each day to this, it makes the task much more manageable than trying to understand and remember it all within a day or two.
Save your notes
Medications come up over and over again and may be applicable in multiple courses. You’ll learn about magnesium sulfate in your OB/women’s health course, but see it again in med-surg and/or critical care as well. Keep track of notes, paper or electronic flashcards, and memory devices. Even if they’re ridiculous or inappropriate – if it works for you, it works.
And don’t make the mistake of forgetting the awesome memory device you created – make sure you write it down! That way when you go back to studying for another course, you can pick up where you left off rather than trying to think of another way to remember the information.
NCLEX® tip! Chances are if you get a medication question on the NCLEX, it’ll be the generic name of the medication and not the trade name. Make sure you know these, which can be a bit challenging since they’re typically longer.
Do what works best for you
Pharmacology doesn’t have to suck. Be intentional and organized with your study time. Focus during this time – close your apps, your phone, and focus. Do this for 20-25 minutes at a time, followed by a break. Repeat for a few hours, then take a long break.
Leverage resources that work for you, not your friends, your classmates, or your instructor – you! That may look like listening to the MedMaster Podcast during your commute, a flashcard app while you’re waiting for class to start, and the Khan Academy free YouTube vides to solidify the mechanism of action… or that may look like the textbook for the mechanism of action, paper flashcards, writing things out, and quizzing yourself. Figure out your unique recipe for success and stick to it!
There are quite a few different options here from podcasts to blog posts to courses and even a subscription services.
However, my favorite and one with the most bang for your buck is the NRSNG Academy. Their medication resources built into each course, and it’s pharm course, are incredible. You can use it throughout your entire nursing school journey, not just for pharmacology. Every single module has NCLEX® points, they also have a simulation NCLEX exam, a massive database of NCLEX practice questions in addition to a huge content review in Fundamentals, OB, Peds, Med-Surg, EKG, Cardiac, Pharmacology, Labs, and my favorite… Test Taking.
Epocrates – a really popular medication resource used by many clinicians and hospitals
Micromedix – expensive to purchase yourself, but many hospitals have this available. Check it out, it is incredibly valuable. At my last hospital, there was a Micromedix link within the Medication Administration Record (MAR) of the Electronic Health Record (EHR) and I used this reference everysingleshift.
All across the country, nurses are in demand, which makes it a very attractive career choice. However, the nursing field is very demanding, requiring specialized knowledge obtained from an advanced education. That can be a financial challenge for many nursing students, especially for those who choose the Bachelor of Science in Nursing path. Many new nurses are left with a mountain of student loan debt.
What Nurses Who Recently Graduated Need to Know About Repaying Student Loan Debt
The total cost of a college education and completion of a nurse practitioner (NP) program can exceed $100,000. So, it’s not surprising that the majority of NP program graduates are among the millions of who leave school with an average of $31,000 in debt.
Nurse practitioners can earn a good living, but with loan payments that approach 25% of their income, NP grads can easily become a part of the 40% of student borrowers who are in or near default.
Fortunately, the nursing profession is so revered that the federal government has created a number ways to ease the burden of student loan debt for student nurse graduates. While student nurses have access to the same range of federal loans and repayment options as any other student, they also have access to special loan programs and repayment plans designed specifically for students in the health care field.
Federal Loan Repayment Options
Nursing students, who attend a two- or four-year college in pursuit of a nursing degree, can apply for federal student loans. Depending on their financial status, they can qualify for subsidized or unsubsidized loans.
There are also additional federal loans for nursing students offered through the Nursing Student Loan program. These loans, available to nursing students pursuing a nursing degree through an Associates, Bachelors or Masters program, are offered by the school’s financial aid department.
Federal loans have standard repayment terms of 10 years. If their loan payment creates a financial hardship they can select from among several income-driven repayment options which cap the loan payment based on a percentage of discretionary income:
Income-Based Repayment (IBR): Caps loan payments at 10% of discretionary income with loan forgiveness available after 25 years.
Income-Contingent Repayment (ICR): Caps loan payments at 20% of discretionary income. Available for Parent Plus loans.
Pay As You Earn (PAYE): Limited to direct or FFEL loans. Caps payments at 10% of discretionary income.
Revised Pay As You Earn (REPAYE): No hardship requirements. Qualification is based on both spouses’ income.
The availability of these plans depends on your financial situation and the type of student loan you have. All income-driven repayment plans are eligible for early loan forgiveness after 20 or 25 years if you are current with the loan.
Special Loan Repayment Plans for Nursing Students
Beyond the income-driven repayment plans available for federal student loans, nursing students may qualify for special programs designed for students entering the nursing or health care field. These programs typically require a time commitment of two to three years in a qualifying health care facility in underserved or critical shortage areas. You know going in how much of your loan will be repaid by your employer and you are free to move on to other opportunities at the end of your commitment.
U.S. Department of Health and Human Services Repayment Program
For nursing school graduates who work in a high need facility, this program offers to repay up to 60% of outstanding loans. In most cases, the benefits received from these programs are taxed as ordinary income.
Indian Health Service Loan Repayment Program
The program will repay some or all outstanding loan balances for nursing grads who commit to two years of practice in an eligible Indian Health Service facility.
NURSE Corps Loan Prepayment Program
For Registered Nurses who commit to working two-years in a critical shortage facility, they may be eligible to have a large portion of their loan balance repaid. A longer commitment could result in additional repayment. Critical shortage facilities could include public hospitals, nursing homes, and rural health clinics.
National Health Service Corps (NHSC) Loan Repayment
This program is available for Primary Care Nurse Practitioners, Psychiatric Nurse Specialists, and Certified Nurse Midwives who work at eligible facilities. Depending on the type of facility and the length of your commitment, it is possible to have 100% of your loan balance repaid. The types of eligible facilities include, critical access hospitals, free clinics, school based health programs and correctional facilities. Benefits received from NHSC are not taxable.
State Repayment Programs
Most states that experience a high demand or a shortage of nurses offer their own version of a repayment plan. For example, Colorado will repay up to $50,000 for a three-year commitment to an eligible facility. Nurse practitioners in Pennsylvania can receive up to $60,000 for a two-year commitment. Washington requires a three-year commitment at a qualifying facility in exchange for repaying up to $75,000.
This program offers complete loan forgiveness for eligible federal loans after 10 years of full-time work in public service, including most health care-related fields. Borrowers must be in good standing after making consecutive payments for those 10 years. The program requires that you work a minimum of 30 hours a week for an eligible employer. Unlike loan forgiveness under the income-driven repayment plans, the forgiven loans do not trigger a tax consequence.
These repayment programs for nursing grads are among the best available for reducing or eliminating student loan debt. It is important to note that none of these repayment or forgiveness programs are available for private student loans, which is a big reason to exhaust all of your federal loan options before seeking college financing through a private lender.
Also, the eligibility requirements for these special programs vary widely, so it would be important to thoroughly study all of your student loan options and consider your career direction when planning for future loan repayment.
About the Author: Jacob is a self-proclaimed student loan expert and personal finance blogger. Follow him on Twitter @DollarDiligence or on his blog, Dollar Diligence.
Please see my disclaimers page for more information.
Student Loan Forgiveness and Management for Nurses
Most nurses can rely on two things once they earn their degree:
1) they’ve found a lucrative and rewarding profession and
2) they’ll have years of student loan payments to endure.
Because of the growing expense of attending college and earning a nursing degree, that second part of the equation can be a real downer. Fortunately, an array of student loan forgiveness options exist and even some specifically for nurses.
Student Loan Forgiveness Options for Nurses
With average student loan debt hovering at around $35,000 for the class of 2015, current and future nursing graduates would be wise to explore loan forgiveness options sooner rather than later.
Here are some of the most popular student loan forgiveness options for nurses and what it takes to qualify:
Federal Perkins Loan Cancellation and Discharge
Since Federal Perkins Loans were created to assist students with serious financial need, they offer one of the best loan forgiveness options. If you work full-time as a nurse, you could get 100 percent of your Perkins loans discharged after five years.
Qualifying for this program is fairly easy. First off, you must have Federal Perkins Loans and be in good standing. Second, you must apply through your school that disbursed the Perkins Loans or through your loan servicer.
NURSE Corps Loan Repayment Program
The NURSE Corps Loan Repayment program was created to incentivize nurses to work in critical shortage areas. To qualify, most nurses need to commit to a two-year work agreement in a critical shortage area as defined by their state or municipality.
Nurses who work at least 32 hours per week in their new role can get 60 percent of their existing loans forgiven. By adding a third year to their commitment, they can qualify to have another 25 percent of their loans forgiven.
Applicants are only accepted once per year and nurses must have earned their degree at a school with proper and government-recognized accreditation.
Public Service Loan Forgiveness Program
The Public Service Loan Forgiveness Program, commonly referred to as PSLF, was created to reward college graduates who commit their lives and careers to public service. Through this program, college graduates can have 100 percent of their student loans forgiven after working in a qualified public service position for 10 years.
After 10 years of working at least 32 hours per week in a qualified position, loans under the Direct Loan Program can be wiped off the map. This program is an especially smart option for nurses who may lean towards work in public service anyway.
The best part is, unlike forgiven loans under some income-driven plans, loans forgiven through PSLF will not count as taxable income, and therefore, won’t result in a hefty tax bill.
In addition to loan forgiveness programs offered on a federal level, 33 states also offer local loan forgiveness programs that can help nurses.
For example, the Wyoming State Loan Repayment Program offers up to $20,000 in loan forgiveness after two years of employment in a critical shortage area. Also on the list is the Colorado Health Service Corps program, which doles out up to $50,000 in loan forgiveness for nurses who work full-time at a qualifying organization for at least three years.
Different states offer their own versions of loan forgiveness for nurses, with unique requirements and payouts depending on the type of the program and the criteria that must be met.
Managing your Student Loans – With or Without Forgiveness
Even if you decide not to work in public service, which often means a lower salary and less-than-desirable locale, there are options for reducing your student loan burden.
If you have good credit, a solid employment history, and are willing to forgo federal protections such as PSLF and income-driven repayment options, refinancing might be the way to go. Private lenders like Earnest and CommonBond might be able to give you a much lower interest rate, saving you thousands of dollars over the life of your loan.
Whether you’re a nurse who is tired of struggling with student loan debt or a future graduate who is already stressed over your future payments, it’s smart to research different repayment options to see if one might be right for your situation.
With some research and planning, you could escape a lifetime of student loan debt and instead focus on growing your career as a highly valued medical professional.
About the Author:
Andrew Josuweit is the CEO of Student Loan Hero, a company that combines easy-to-use tools with financial education to help the millions of Americans living with student loan debt manage their student loans smarter. Student Loan Hero is helping 150,000+ borrowers manage and eliminate over $3 billion dollars in student loan debt.
Preparing for the NCLEX is a daunting task. I took the NCLEX back in 2010 and passed in 75 questions in 1 hr and 20 minutes. I’m not a great test-taker and wasn’t a 4.0 student. I did, however, do what I outline in this post. I wanted to share my thoughts with you in hopes that it’ll help you in preparing for the NCLEX so you don’t feel like you’reguessing at a good approach in both studying and mental preparedness. You don’t have to be an A+ student to pass, but there are some important practical steps to take that can make a big difference in whether you pass or fail. Below are my 4 practical tips for preparing for the NCLEX.
7.5-minute video on preparing for the NCLEX
If you don’t feel like reading, here’s a short video of these tips!
Alright here are the tips I go over in the video, but in more depth!
1. Don’t fixate on 75
A lot of people will get a mental goal of passing in the minimum required (75 questions). However, if you fixate on that and anticipate it shutting off at 75 questions (and therefore consider yourself a failure if it doesn’t) it’ll psych you out unnecessarily. I’ve never had a patient, loved one, colleague, or… well, anyone ask me how many times I’ve taken the NCLEX, let alone how many questions I answered.
Let go of the desire to live or die by 75
Man, that was pretty poetic wasn’t it 🙂
2. Know how it’s structured
The NCLEX is NOT like other exams. It is a computer adaptive test. What’s that, you ask? Basically, the first question you are given is of medium difficulty. If you answer it correctly, you’ll be given a more difficult question. If you answer it wrong, you’ll get an easier question. They will keep asking you questions until they can definitively decide if you are above their predetermined passing standard. The NCLEX does shut off if it determines that you will not be above the passing standard as well.
Here is really informative link on computer adaptive testing from the National Council of State Boards of Nursing (yes, the people who write the NCLEX!). And here is a great 6-minute video explaining computer adaptive testing from the NCSBN as well. Please, please watch this! (I promise it’s not a workout video…)
3. Pick a plan and stick to it
There are a lot of NCLEX review options out there. Whatever you pick, develop a study plan and stick to it. You must be disciplined right now; it is not the time to kick back, do a few practice questions, read a few pages of an old text book, and give it a try. Be active and intentional with your studying. Do not be passive and relaxed. Focus.
I took Kaplan’s in-person review course in 2010, and answered 25 questions each day (6 days/week) up until I tested 1.5 months later.
There are many companies that you can purchase NCLEX reviews from. Which ever company you go with, I recommend sticking to their information and not overwhelming yourself by cross referencing everything with the 400 textbooks you acquired during nursing school. If you get the NRSNG Academy, stick to those resources and only cross-reference when needed, not with every point. If you get the Kaplan course, stick to the book they provide to you.
Let’s dive deeper into NCLEX reviews…
NCLEX review options and considerations
There is quite a bit to consider when you’re picking out which NCLEX review material you’ll focus on. Let’s chat specifically about types, considerations, and the top options out there.
Types of NCLEX reviews
In-person review (you physically go there), online-review (similar to an online course), written materials (a self-guided book), content review (access to online or print reference material in various media formats), apps (reference material provided in a smartphone application), and the most important aspect.. NCLEX-style question banks.
You MUST get a course with a question bank. No questions asked…
Seriously. Don’t buy a course or resource without one. The key to success is answering practice questions on a regular basis until you test. Period.
Things to consider when selecting an NCLEX review course
Below are some good questions to ask yourself as you select a review plan. The questions marked with * are of particular importance!
Do you get your money back if you don’t pass?
*How many questions are in the question bank?
*Do the questions provide rationales?
Can you afford it?
Does their teaching method align with your learning style?
Do they have an option to use their content on mobile?
Pro-tip: answering questions on your phone while you’re waiting on a bus, in line at the store, or whatever, is a great way to sneak questions in
Do the provide you with a simulation NCLEX?
Can I try it out before I buy it?
*Do they also provide test-taking strategies?
Do I know anyone who has used it before? What’d they think?
Kaplan, Hurst, and ATI are the big company ones. They provide similar materials and options, and their prices aren’t terribly different from one another. I took Kaplan as a new graduate in 2010. They provided test-taking skills (essential), a question bank, in person course, textbook, and a pass guarantee.
If you just want the Kaplan content book (which I thought was pretty good), here is an Amazon link:
NCLEX Mastery is a smart phone app. I personally haven’t used it and not sure of others who have, but it’s got a ton of reviews!
NRSNG / NRSNG Academy is a question bank, large content review, simulation NCLEX, audio files, case studies, image database, and more. You can also get a 7 day trial for just $1.
(Full disclosure, I taught the mental health and OB courses, but I love all of our resources and the thought that goes on behind the scenes… and that they all come from nurses, not big companies!)
4. Bring down your anxiety threshold
The NCLEX is a big deal and creates anxiety in even the calmest of individuals. Spoiler alert: we’re all nervous about the NCLEX, some are just better at pretending than others. Even if you don’t struggle with anxiety, this test will make you worry and anxious. The last 2-4 years culminating into one big scary exam is no fun. However, there are some active steps you can take to get control of it.
Know what to expect on NCLEX exam day
The more unknowns you can remove from the day, the better. Check out this great resource from the NCSBN (again, the people who wrote the NCLEX!) about what to expect when you go to take your exam. They go over things like what to bring, what not to bring, acceptable forms of ID, breaks, and more. Click here to check it out.
Naturally, security and identification is a big deal at NCLEX testing sites. Therefore, they have very strict rules that you must follow. You don’t want to get there unprepared and unable to test.
Plan out your NCLEX exam day
Once you know where and when you’ll be testing, start planning. If you test at 8:00 am in a city that’s 2 hours away, consider that travel time. Do you have to worry about driving and traffic? Do you know where you’re going? The more structured you can be and the more predictable the day is, the better. Maybe you’ll want to get a hotel nearby so you don’t have to stress in the morning about the unknowns. I tested at 1:00 pm in a city about 2 hours away. My husband drove me, we went really early and grabbed lunch nearby, and was at the testing center about 45 minutes early. I walked in… and right back out about 1 hr and 20 minutes later!
Figure out where you will go, when, where you’ll park, and any other little details.
Meditate the week before / become a Yogi bear
I know this sounds odd you guys, but it works. If you can meditate for 15-20 minutes twice a day for at least a week before the exam, you can help reduce your anxiety threshold and get yourself in a better frame of mind. Yoga and meditation are a great combo… especially after you sit and stare at a computer for longer periods of time, answering practice test questions.
(If you have medical conditions, please make sure you check with your doc.. however, these are really light exercises and more about mindfulness, so they theoretically should be appropriate for most individuals.)
Here is a great video where you can do this in the privacy of your home, for free.
Trust your plan
Once you’ve read what you need to, planned out your studying and NCLEX exam day schedule – trust in that. Don’t try to over-control it all. Stick to your plan, be active in anxiety prevention and studying, and trust yourself. You’ve got this.
There are a ton of resources out there. Some great, some… not so much. In my personal experience, one of my favorites and most cost-effective options is the NRSNG Academy. Every single module has NCLEX® points, they also have a simulation NCLEX exam, a massive database of NCLEX practice questions in addition to a huge content review in Fundamentals, OB, Peds, Med-Surg, EKG, Cardiac, Pharmacology, Labs, and my favorite… Test Taking.
Click here to try out all of the below courses, question banks, flashcard app, and more for only $1!
And, here are some more to check out that were all written by nurses!
This post on the Master of Science in Nursing (MSN) FlexPath program is sponsored by and crafted with Capella University; however, all opinions are my own.
At the beginning of last year Capella University launched a new learning format for their RN-to-BSN program they describe as self-paced called FlexPath. Being a self-starter that style of learning was very intriguing to me, but since I already had my BSN, it wasn’t really applicable to me. However, Capella has just announced their Master of Science in Nursing (MSN) FlexPath program*! Capella’s MSN FlexPath program is the first of its kind. No other university offers an MSN with this type of groundbreaking learning format. Since I am interested in obtaining my MSN with a focus on Nursing Education, I really wanted to learn more about what obtaining a self-paced online degree would actually look like.
Capella allows anyone to try out this format with a FREE FlexPath trial course. So… I tried a course! I wrote this post so you could see my genuine thoughts as I checked out this new style of online learning. It’s important to me to be able to get an idea of what something like this would be like before taking the big plunge into an MSN program.
I am intrigued by FlexPath because my schedule fluctuates quite a bit, so committing to a normal college course timeline and pre-set due dates isn’t really an option for me at this point in my life. I have periods of time where I can get a lot done, but others where I am very busy and probably couldn’t meet the deadlines of a more traditional online format.
I haven’t taken a full online course since 2007 and my experience at previous institutions was less than awesome. The structure of the course made it difficult to find due dates, communications, and documents. Oh, 2007… I was probably waiting in line for the Harry Potter and theDeathly Hallows to come out while I was looking at prices for Blu-ray discs to replace my DVD’s on my Blackberry, and missed a discussion post. Typical.
For those of you who are not familiar with Capella’s FlexPath learning format, it is a different way to obtain your degree than the typical online experience. Here are the big benefits FlexPath offers that you won’t get in a more traditional online format.
A new level of flexibility – With this 100% competency-based program, you can set your own deadlines and there are no discussion posts, so whether you finish a course in 2 weeks or 12, it is up to you. You dictate your pace (if you have more time and want to be more aggressive with your deadlines, or have a lot going on and need more time). Once you are done, you move on to the next course without waiting.
Different cost structure – with FlexPath you pay per 12-week billing session, not per credit hour. And with the self-paced structure, you complete as many courses per session as you can, for one flat tuition fee** (which enables me to budget better) for that period of time. Therefore, the faster you progress, the more you save. For example, pace your MSN faster to graduate in 1 year at under $10,000. For a more moderate pace, finish in 2 years at under $19,500.
Your experience matters – There’s nothing I appreciate more than when my existing knowledge is considered. I’m not completing unnecessary assignments that are not beneficial to my specific needs. Every nurse going into an MSN program brings different skills sets and experience to the table, and I like that my unique experience matters as I progress my education. It also means I’m not using my valuable time to do something I already know how to do.
Different levels of support – In any online program, occasionally you have clarifying questions for the professor, but sometimes you just need some pointers, minor clarification, or technical help. I hated sending an email to my professor about something minor (but important) and waiting 4 days to get a response because they were so overloaded with similar messages and tasks. I like that there’s someone specifically for logistic help (FlexPath coach), someone for content assistance (FlexPath tutor), and then my professor. They also have additional resources like a writing center, career center, librarians, and so forth.
Exploring FlexPath Course Structure
This was set up much better than my previous courses. But that’s not terribly shocking since it’s been almost 10 years (gasp!) since I’ve taken one.
The trial course shows you what a real courseroom would look like. You’ve got navigation on the left side with links to your progress within the course, required assessments (essentially your major assignments), the syllabus, notifications, and tools. It looks like you spend most of your time under the assessments tab, which is where your assignment-specific information is located.
Here is a screenshot of the trial course home screen:
An unexpected surprise was the classroom’s ease of use and the intuitiveness of the online platform:
When you click on links or buttons, it opens a new tab. I know that’s a small thing, but when you’re doing this a lot, it makes a big difference to have necessary pages or documents in their own tab.
The scoring guide is really obvious. I can easily tell what is expected of me.
The syllabus is part of the navigation. This means I can quickly access it and am incapable of losing it. (Score!)
When I need to look up a resource from a journal or database, it’s within the dashboard. This subtle feature makes things substantially more convenient because I don’t have to log into another website to get what I need.
You can chat online with a librarian during specific hours. Guys. I hate the phone… like, with a passion. The ability to do an online chat when I need help compiling resources (which I needed many times during my undergrad) is simply magnificent.
Setting Your Deadlines
We chatted a bit about setting deadlines, but I wanted to show what that actually looked like. Remember, you read your assessment and then you decide how long you think it will take you? Here’s what it looks like when you set your deadline:
Submitting a FlexPath Assessment
For each assessment, you are given an overview of the requirements and what success looks like. It reminds me of the prompt for a paper. How many of us have Googled our assignment just to get an idea of what the professor was talking about?
Writing a paper? Compiling APA resources? Discussing my knowledge? No 50 question timed exam over 400 pages of material? No test anxiety?
I think assessments are my new love language.
After you get your mind around what’s expected, you then set your target completion date. If you’ve got questions, there are links to connect with a facilitator, tutor, or instructor. No, not sending emails back and forth, thank gosh… my inbox is already fuller than the trashcan outside of an isolation room.
They also provide a scoring guide, which again, is really helpful. I’ve written some papers but not been aware of how I was actually going to be graded.
I wrote my trial course assessment and uploaded it per the instructions. It stated that I would have facilitator feedback within 2 business days. I received my feedback and a grade about 2 business days later. There was an entire page-long written response to my assessment, followed by a grade… which was kind of cool to see, even though it was just a trial course.
What Everyone Cares About Most – How You’re Graded
Writing is my personal strength, not taking tests. I’m what you’d call a poor test-taker. I’m a terrified tester. Tumultuous test-taker. Turbulently tearing tests…. Okay I’ll stop now.
I’m bad at tests.
Even things I know beyond a shadow of a doubt… I doubt under pressure. (You pull out your calculator on your phone for 8+6 too? Great.) I would much rather leverage resources and synthesize my thoughts into an authentic assessment based off of my timeline versus taking an exam to demonstrate my knowledge. I think that’s a much more effective way to learn because I’m showing that I really have mastered a concept and haven’t simply memorized facts for a test. I’m leveraging my resources available to me to come up with an appropriate response… sound familiar? It reminds me of when I’m working at the bedside, utilizing what I have at my fingertips (policies, procedures, medication references, other member of the healthcare team, online databases, and quite a few more things) to deliver the best care possible to my patients.
Here’s a little more in-depth about how learning is assessed:
After really diving into the trial course, I feel like this is a step up from the regular online learning options out there in terms of personalization and accountability. So if you are motivated, focused and self-directed, this would be a great fit for you. However, if you need more structure, FlexPath may not be the best option. But don’t worry, Capella also offers the MSN in their more structured online format: GuidedPath, so you have options.
When I was fresh out of high school, this probably wouldn’t have been ideal for me because the transition from high school to college was a steep academic learning curve for me. But now, this learning format is ideal for my learning style.
My Final Thoughts on the Master of Science in Nursing FlexPath Option
I was pretty blown away at FlexPath after trying the trial course. I have been putting off getting my MSN because I simply haven’t had the time and was overwhelmed at the simple thought of the pre-set deadlines. However, after really jumping in and seeing what it would practically be like, I’m ready to take the plunge. I’ve actually decided to go ahead and begin my MSN with a focus in nursing education in the next coming months at Capella through the FlexPath format.
If you’d rather do more of a traditional-style of online learning, there is always Capella University’s GuidePath option. This option includes due dates set by the instructor, discussions, and/or other assignments.
Also keep in mind that the BSN, MSN, and DNP degree programs at Capella University are accredited by the Commission on Collegiate Nursing Education.
Have you taken any FlexPath courses? What did you think?
*This offering is currently not approved for federal financial aid by the U.S. Department of Education (ED).
But, there is no shame to my organization and preparedness game. This results in less stress and therefore more time to enjoy life and relax.
If you’re anything like me, whenever something unknown is on the horizon, you do all that you can to get a head and be prepared from the moment it begins. Nursing school is one of those big unknown scary things. I’m going to go over a few things that will help you stay ahead in nursing school despite how overwhelming and demanding it is day to day.
Start preparing for the NCLEX on day 1
Don’t wait until senior year to start thinking about the NCLEX. The way this exam is structured and the format of questions is very different from other exams. It’s what’s called a computer adaptive exam, which means it’s different for every single person. It is not like nursing school exams.
Here’s a book I highly recommend for test taking skills in nursing school
Because it’s so different, I highly recommend picking your NCLEX review plan early (I go over options in that in the Preparing for the NCLEX post), start getting into a routine of taking NCLEX prep questions immediately (just a few a day) even if you don’t know the content behind them yet, and getting your test taking skills down early for both general nursing school exams and the NCLEX
The sooner you start to build that NCLEX foundation, the better.
Merely skim chapters beforehand
Don’t get all in-depth and try to fully comprehend a chapter or concept before lecture. Merely expose yourself to the content. Get a general idea of what you’ll be going over. Understand some basic definitions. Don’t make the mistake of trying to read the entire chapter, word for word, highlight 75% of it, then get frustrated when you answer sample questions wrong.
Conversely, don’t make the mistake of not reading anything beforehand either. Going in cold to a lecture will leave you behind, as you’re trying to look up the basic definitions to terms that professors just whiz by.
Get an idea of what’s ahead so lecture isn’t the first time you’re hearing the term percutaneous endoscopic gastrostomy, which the professor keeps referring to as a PEG tube and you just spent the last 10 minutes silently figuring that out while he’s now describing an EGD.
In between my junior and senior year, I completed a 10-week nurse residency program. I basically shadowed another nurse. It was incredibly helpful. I was able to physically see the things we were talking about in theory that I didn’t have a chance to see in nursing school clinicals simply because there wasn’t a patient there with that particular issue, procedure, or medication. I remember specifically wanting to see a ventilator because I knew my critical care course was in the fall. I learned about so much respiratory equipment over those 10 weeks, which seriously enhanced my understanding. If you don’t have the opportunity to complete an internship – volunteer.
Most facilities use volunteers, and while you won’t be physically doing procedures, you’ll at least be able to observe. I volunteered in an emergency department in college and learned so much by simply being there. I saw how they dealt with a combative patient who overdosed… I saw how they ran codes… I saw how they dealt with death… I saw how the team functioned.
Don’t look at your reading assignments as just a to-do list
When you’re trying to get ahead, it’s easy for it to turn into something to just check off as done on your to-do list. But in this situation, you really need to try to learn and understand things deeply, not merely get things done to be successful in nursing school. Switch the mentality from getting it done to truly understanding it. Look for “ah-ha” moments in the text. Understand the concepts, don’t just memorize the text. If you don’t finish every word of a reading assignment, but now you really understand the pathophysiology behind atrial fibrillation, count that as a win – not an incomplete.
When I was in school, I didn’t look for the “ah-ha” moments in the text – I just tried to get it done. I personally got pretty bogged down by all the fluff in the textbooks because I didn’t know where to focus. It can get pretty tough to identify the information that will lead to your “Oh, now I get it” moments. When you find them, make sure you take note and focus there.
It’s not about checking off a to-do list, it’s not about getting a certain grade. It’s about understanding the information so that when you are taking care of patients, you’re making the safest decisions at every turn.
How to connect the dots
Finding those aspects of the content that really turn it from something textbook to something that really makes sense is challenging, especially when you’re responsible for reading so much information for each exam.
So, what do you do?
Here’s a nurse pro-tip: look for the linchpin.
What’s a linchpin? It’s an “ah-ha” moments… the most important concept of a complex concept or situation. It’s what connects the dots.
So how do you find these within a 400+ page reading assignment… every single week?
Another nurse pro-tip: don’t.
Someone else has already done that for you.
A former nursing student realize this and got together with some other nurses to create a hub of resources that consistently only of these linchpin moments. Concise courses of content review along with practical study tools.
10 different courses that are only the linchpins – presented in a concise format. And this includes a Test Taking course.
If there is one thing I recommend completing BEFORE the first day of nursing school, it’s taking the Test Taking Course. You’ll begin nursing school with test taking skills I didn’t figure out until junior year.
I went to nursing school from 2006-2010. I am a terrible test taker. I wish I had this course in 2006 to get a foundational test taking knowledge before beginning nursing school. It would have made a WORLD of difference, and I wouldn’t have wasted so much time doing things incredibly inefficiently.
You can try the NRSNG Academy, access to all 10 courses, the a bank of 3,500+ NCLEX practice questions, the simulation NCLEX (SIMCLEX), Flashcard App, image and audio database, and cheat sheets in every course – for only $1.
My advice – try for $1, but go straight to the testing taking course and complete that course within your 7-day trial. That course is just the tip of the iceberg within the academy, and sets you up for success in nursing school with exams, studying, note-taking and the NCLEX.
I recently started a hashtag on Twitter asking experienced nurses for their input on clinical tips for nursing students. I thought the response was incredibly helpful and valuable and I wanted to to share these clinical tips with you!
Experienced nurses – What other tips for nursing students just starting clinicals do you have?
This week I am featuring an interview with my sister in-law, Elizabeth Fields. She recently went to Bora, Ethiopia with the medical mission group Health Gives Hope. Last week, I interviewed their founders, one of whom is actually a Nurse Practitioner! Click here to check out the previous post.
To give you a little background about Bruce and Elizabeth Fields, they are quite the athletes and world travelers. Bruce played professional basketball in Europe for 9 years and now works at State Farm in the Chicagoland area. Elizabeth played volleyball at Parkland College (where I played basketball for a short time!) in Champaign, IL and then completed her BSN at Indiana Wesleyan University while continuing to play volleyball. She has worked at Northwestern Memorial Hospital for the last ten years as a registered nurse, working the last two years as a Nurse Practitioner. She obtained her FNP from Walden University.
These two crazy kids. They met in Austria some odd years ago and have traveled to the following countries either together or separately: Turkey, Switzerland, Austria, Thailand, Ethiopia, France, Italy, Belgium, Norway, Spain, England, Philippines, South Korea, China, Russia, Ukraine, Poland, Germany, Mexico, Japan, Denmark, Canary Islands, Romania, and Canada. Oh, and Bruce has lived in a handful of them as well! Clearly they know a bit about traveling! Me, I’m more of anxious traveler (think Monica Gellar going to London).
I decided to interview them to give people a look into the practical side of what going on a medical mission looks like. As you read, Bruce is not medical. However, what he lacks in nurse-ness, he makes up with hard work and height. (He’s 6’5″.)
Please note, answers given below are from Elizabeth, unless otherwise indicated.
Why did you decide to go on a mission?
I went to Bora, Ethiopia because they don’t have access to health care, and this was something I could not only make a difference doing, but I knew it would grow my knowledge and stretch me professionally. I also went on a mission trip to live out something I was taught and believe in deeply: you should use any talent you are given to bless others. Nursing is a talent that was given to me and I am passionate about sharing it.
What was the travel there like?
This is from the HGH website: The team flies from the US to Addis Ababa, and then drives south through the lower rift valley into the Guge Mountains of southern Ethiopia. The team will then hike 6 miles, ascending nearly 2,000 feet, from where the road ends in Chencha to the village of Bora.
Travel in Africa is entertaining and challenging. We were on planes, boats, buses, and on foot – our baggage traveled up the mountain by donkeys and our road was often congested with cattle, camels, and people.
Tell me what was going through your mind the first time you saw their set up for medical care?
The clinic set-up is smart, efficient, and well planned – their resources are growing – but the first thing you think is – “WOW – they have access to SO LITTLE compared to what we are used to; how am I going to make it work?”. But then, you make it work, and realize how MUCH we have in the States and how profound your assessment skills are!
What are some of the biggest differences between the care you provided there versus in the USA?
We had no access to running water, internet, or specialty consults. We had no diagnostic testing. I had to be excellent in my history and physical taking, and in my assessments so that I could determine differentials and treat appropriately. The creativity needed to get medications into infants, translate reasons, times, importance and information to patients was profound. The translators were amazing, but I have to hand it to the nurses – they had so many amazing ideas to help make these challenges ones we could overcome.
What were your meals like?
AWESOME and different! It was a mix of American food and authentic Ethiopian foods. The people there are extremely hospitable and loved cooking for us. We got to observe and help them cook in a “cooking hut”, and experienced what is like to cook without any modern conveniences. Some of the meals they made for us I have tried to recreate here, and have been moderately successful in accuracy.
What were the sleeping conditions?
We slept in mud huts, on straw, in our own sleeping bags. At first I struggled with the conditions – it is exactly like you would see it in the National Geographic! But looking back, I wouldn’t have wanted to sleep anywhere else; I lived and experience it in the most authentic way possible.
Tell me the bathroom situation, STAT.
Bathroom? You mean tell you what it was like to squat on a gorgeous mountain side and hope no animals or humans saw my southern regions? Two words: wet. wipes.
Tell me about some practical cultural differences.
One of the things that hit us hardest was the reverence and respect for elders that everyone had. Here in the states the elderly population is often viewed as a burden, while in Ethiopia they are cherished and consulted for their wisdom. Another shocking difference was how hard the women worked. The Ethiopian people often refer to women as “provider”. You will see in our pictures that women do the heavy lifting there.
Elizabeth, walk me through one day as an NP there.
I had two interpreters assigned to me. Each patient would come in my exam room, tell me their complaints/history, and symptoms. I would do an examination, diagnose their problem, and prescribe medications (pending availability). When I had a patient that “stumped” me, I called upon the other practitioners and nurses for their expertise. Because we had no diagnostic testing available (labs, X-ray machines) collaborating was our lifeline; we all needed each other to make each day in clinic work and it was an incredible experience!
Bruce, walk me through one of your days there.
Every morning we wake up and walk from our hut down the mountain to a place we called “the cliff”. It was an incredible time to enjoy a beautiful view and reflect on our days there. We then returned to our compound to have breakfast that was made for us by the locals. It consisted of grains, potatoes, sauces, and amazing Ethiopian coffee (FYI, Ethiopia is the birthplace of coffee). We hiked up the mountain a mile to the clinic every morning, with the village children holding our hands the entire way — this experience melted my heart.
My time in the clinic consisted of building shelves, setting up a privacy tent for the bathroom over a hole dug by a previous team, working in the pharmacy dispensing the medication prescribed by the practitioners, and helping teach patients how and when to use them. I often made lunches for the entire team with another group member and did what was necessary to ensure a good flow at the clinic. I was concerned that because I’m not medical I wouldn’t be very useful, but when I got there I found the opposite to be true. We each had a role and without each other it would’ve been impossible for the clinic to be successful.
How much did it cost?
About $2500 a person, and this included flight, ground transportation, lodgings, food/water, two days of sight-seeing. It was the cheapest 2 weeks abroad!
How do you feel this impacted your marriage? Do you recommend married couples going together?
YES! GO TOGETHER! My husband isn’t medical, but the need is so great and watching him use his gifts in service by building shelves, working in the pharmacy, making team lunches, setting up privacy tents, and playing with the kids was – well, SWOON. I can’t exactly bring him to work with me to see patients here in the States; watching each other in our own elements was amazing. It gave us greater respect for one another, and made me want to encourage him more in what he excels in.
I know these experiences are hard to predict how they will affect you. What did you anticipate versus what did you experience?
I didn’t expect to want to stay there longer – but I was so sad to leave. There are days at work when I find myself in the grind of the day, burnt out and discouraged; to feel so needed and impactful in Bora, Ethiopia was priceless, and it took me off guard. I didn’t know I would fall in love with medicine again – I didn’t know that I needed to be there for my own benefit, just as they needed me there.
What did you learn that has changed your practice as an NP in the US?
Because I had to rely so heavily on my assessment skills and collaboration with the team when I was faced with a questionable diagnosis, I have worked much harder to perfect those areas since I’ve been back. Those areas include knowledge and differentiation of various heart and lung sounds, alternative treatments, and preventative medicine. My desire to be a better provider has substantially increased since going to Ethiopia.
Would you do it again?
We would go back tomorrow. Without blinking. It was professionally and personally something that humbled us, empowered us, and revitalized my passion for medicine and nursing.
Last month, my nurse practitioner sister in-law went on a medical mission to Ethiopia with her husband. She had an unbelievable time! I have been asked about medical missions before so I thought I would do an interview with the founders of the organization and my sister in-law.
This post is my interview with the founders, Amber and Jerry Kaufman.
All answers below are from Amber, unless otherwise noted.
(Also, please note Jerry’s solid beard.)
Amber and Jerry!
Amber, I know you are a nurse practitioner. Where did you get your nursing degree and your NP? Do you still work in the USA as an NP, if so, where?
I got my nursing degree from Purdue University. I initially became a Pediatric NP from the University of Central Florida. I later got a Post-Master’s Certificate for adult NP from University of Massachusetts – Boston. I currently work as an NP with One Medical Group.
Jerry, what is your professional background?
I am a Ph.D. student at the University of Chicago. My areas of interest are health, globalization, race and ethnicity, and organizations.
Why did you both start going on medical missions?
Amber: When I was in high school I heard a woman speak about doing medical mission work in Papua New Guinea – from then on, I knew that I wanted to do it. As soon as I had my first clinic day in India, my first medical trip, I knew I was hooked. Little did I know that I would be where I am today in 8 years!
Jerry: I’ve been involved with international nonprofits for over a decade, so I’ve been interested in international work for a long time. I got into medical mission because, well, my wife!
Where was both of your first medical missions?
Amber: My first medical mission trip was to India.
Jerry: My first medical trip was to Ethiopia.
Why that particular region of Africa?
Honestly, it just fell into place. We were set to go to another country with a medical team and the trip fell through due to political unrest. The other co-founder, Dan, happen to know someone from college that was teaching in Ethiopia. We asked if we could bring a medical team in 5 weeks to Ethiopia and she said yes. She introduced us to Israel, who is now the Health Gives Hope Program Director in Ethiopia (4 of his siblings also work with us). Israel was our leader for the trip. Amber knew right away that Ethiopia was were we were suppose to work. And here we are 7 years later with a health center and teams going twice a year. Amazing!
What are some practical differences in the way you provide medical care in Ethiopia versus the US?
You have to make due with less. We have solar powered lights but that’s it for modern conveniences. No running water and limited supply of medications. We don’t have access to labs and diagnostic testing. In emergencies or for critically ill patients, we will transport them to the nearest hospital. But for the most part you use the patient history and exam to make your diagnosis and treatment plan. It is a challenge, but rewarding.
What do the villagers do day-to-day for medical cares/concerns when you do not have a group there?
We have a nurse that travels from a nearby town, Chencha, and works at the health center we run in Bora (Hidota Health Center). She works 3 days/week to provide care. If she is not there, the people either have to walk 6 miles to Chencha or they don’t go, which is usually the case.
Hidota Health Center
Every nurse also has a patient experience that they can look back upon and say “I am a better nurse because of this person” or “I am a better nurse because of this particular patient experience”. What specific patient experience from Ethiopia has made you a better nurse?
On the 2nd trip to Ethiopia, we had our clinic set up in a local church and we were seeing patients there (the Hidota Health Center was still a few years away!). A father came frantically to the clinic and asked if I would come see his wife who had just given birth during the night. He just kept saying she was sick. I packed my backpack full of medical supplies – trying to think of every possible scenario I might encounter. We hiked down the mountain about a mile to their hut. A woman was lying there and clearly not doing well. After a quick assessment and history, I determined that she was severely dehydrated (she hadn’t had any water in about 36 hours – and delivered a baby in that time!) and she had a possible early infection. I gave her IV fluids and IV antibiotics. We stayed with her much of the afternoon until she turned the corner and started feeling better. I assessed the baby who was happy and healthy! By the time we left, the mom was able to sit up and drink water on her own. The family then told me that they decided to name their baby “Amber.” It was an incredible moment. I was so thankful we were there – otherwise, I am not sure that mom would have made it.
In nursing, we learn tricks of the trade in our day to day practice. I have a feeling that tricks of the trade in providing nursing care are a bit different in Ethiopia are different than in the US! What are some tricks of the trade or pro tips for nurses providing care with HCH in Africa?
Your face and tone says a thousand words! Since you are using 1 or 2 translators (sometimes you need translation from the local dialect to the national language to English), the people are really looking at your expressions. It really does make a huge difference. Also flexibility is a must – in all things, all the time.
Tell me some common rookie mistakes that nurses make during their first medical mission?
Honestly, there aren’t too many. It’s not a mistake but it’s common for nurses to feel bad about the times where we can’t provide the care that is needed (for example, medications or treatments that we don’t have). It can take time to realize that this is just part of working in a rural setting.
Providing patient care!
Tell me your biggest reality shock as a nurse when you first started serving missions?
I don’t know if I would call it a shock…but maybe an area of growth.. For me, learning to slow down and have patience. Things just don’t happen as quickly as I am used to or that I want them to. I have finally arrived at patience, for the most part.
Do nurses need to have a certain amount of experience to serve?
No – new nurses and seasoned nurses are welcome. As long as they are willing to serve, they can join!
My sister in-law (Elizabeth Fields) is second on the left. She’s an NP and the other three are nurses with about 1 year of experience!
Can nursing students serve?
Absolutely. I have also had NP students and I was able to serve as their preceptor for clinical hours.
What is the average cost?
The cost is $1500 for your land package (everything except souvenirs and vaccines) plus airfare. Airfare tends to run between $1300-1600 depending on your departure city.
When many people hear medical mission, they may connect it with a faith-based organization. Do you need to be of a certain faith to serve with your group? Our organization usually calls our trips “medical service trips.” No, you don’t need to be a certain faith.
I noted that you are based out of Chicago. Do people interested in serving need to be from that area? No – we have travelers from all over the country join us!
If I decide I want to serve or learn more, what are my next steps?
Next week, I’ll post an interview with my sister in-law (Elizabeth Kleber, MSN NP about her trip!
For those of you that may be interested in learning more, check out their website! Please note that while these trips are extremely rewarding, the travel can be very challenging physically. Upon arrival to Addis Abada, Ethiopia, you take a 10-12 hour bus ride, followed by another half day drive, then hike for half a day at an altitude of 10,000 feet above sea level up mountains. If you have specific questions/concerns about the travel and if it would be a good fit for you, shoot Amber an email! You’ll hear more about my sister in-law’s experience, both with the travel and her entire time, next week!
Have you ever been on a medical mission? If so, please comment below with where you went and which organization you worked with!
Please note that this post is sponsored by Capella University. All opinions are my own. Please check out this video about my 2016 partnerships and why I’ve decided to work with these amazing organizations.
When I graduated from nursing school I was given a packet of information about the various professional nursing organizations. I was so overwhelmed at that time that I just put them aside and forgot about them. It took some time for me to begin exploring what they really meant, and looking back, I am sad I missed out on that time to be a part of these organizations from the get-go. It really took some time for me to comprehend exactly how big our profession really is. There really are two parts of nursing: the nurse providing the direct patient care, and then the nurses working behind the scenes to support those providing direct patient care. Upon graduating, I had no idea how big (and essential) this side of nursing really is. I think on some level I knew that had to exist in some capacity, but I didn’t realize exactly how essential this piece of nursing is to the entire profession.
Who they are
These organizations are comprised of nurses. When you work for a hospital that is run by business people, it is great to be part of an organization that is run by nurses! While there are groups of various specialties (and practically every single specialty you could imagine!) there is also the American Nurses Association, which is for any registered nurse in the United States. There are also nursing organization for each state as well.
What they do
These organizations provide a host of resources and support to their members. What I find particularly valuable are the publications that most provide. I am a member of the American Nurses Association (ANA), the North Carolina Nurses Association (NCNA), the American Association of Critical Care Nurses (AACN), and the American Association of Neuroscience Nurses (AANN). Every month I receive journals from these organizations that are talking about the latest research, evidence-based practice, and issues that affect that particular patient population or region.
By staying up to date with these you are being constantly informed about the latest information and best practice for your patients. It is quite empowering. This information and access to their databases allows you to know what is most current, what other hospitals and health systems across the country are doing so that you may implement the latest and greatest with your patients at your hospital. Knowing the latest research allows you to engage in educated and thought-provoking conversations with your team members and those that are in decision-making positions at your facility. This is how change happens!
These organizations are also closely affiliated with specialty certification organizations. In most cases the professional association establishes the standards upon which the certification is based. Many specialties offer a certification. For example, the AACN Certification Corporation offers several certifications for critical care nurses. I took that CCRN certification exam in Sept. 2015 and am now a certified critical care nurse!
Why you should join
Professional organizations provide an outlet for your professional development outside of the walls of your facility. These groups will help complete the picture of our profession for you. While the face-to-face interaction with the patient is an essential aspect of our profession, the behind the scenes work is just as vital, and this is where it occurs. They provide many educational and networking opportunities, from online CEUs to national conferences. Many organizations work with schools and provide various scholarships for degrees as well.
How much does it cost?
It really depends on which organization, so I won’t outline it here. However, many hospitals and employers will reimburse for the membership fees. They do this because it furthers your professional development and enhances your career. Most will reimburse after you pay for your membership upfront but some will submit payment for you. It is definitely worth checking out if your employer offers this benefit!
To show you exactly what you get and what access you have with a membership, I logged on to the American Nurse’s Association website with my member login so you can really see what is there. There is such a huge amount of information about so many things and I just want to show you how it is all set up. I also will quickly show you the homepage of the American Association of Critical Care Nurse’s homepage so you can see how much information each group provides. Spoiler alert – it’s a lot.
What I also really appreciate is when schools work with these professional organizations to provide more ways to further your career as a nurse. For example, Capella University and the ANA Leadership Institute are now offering a “Nurse Leader Scholarship” for nurses who want to advance their career and move into expanded clinical and leadership roles. The scholarships, ranging from $4,500-$7,500, are available for Capella University’s Master of Science in Nursing (MSN) program and Doctor of Nursing (DNP) program. Applicants for the scholarship are required to be ANA members as of May 1, 2016, new to Capella and must apply and start by September 12th.
I encourage you, professional to professional, to check out your specialty’s professional organization as well as the American Nurses Association and your respective state organization. Read journals, write to your member of congress, participate in research studies, get more education. You don’t have to be a nurse with a certain number of years experience to be a member and dive deeper into your professional development. You just have to be a nurse!
Please note that this post is sponsored by Capella University. All opinions are my own.
This is some quick info on a few very common meds you run into in the neuro intensive care unit. However, please always follow your hospital’s policies and procedures. This is for informational purposes only and focuses on nursing considerations.. not going in depth on the drug.
Nursing Considerations for 4 Neuro ICU Meds
Propofol or Diprivan
We love this med with all of our neuro hearts. It is given IV as sedation for patients with increased ICP or for patients with seizures. A continuous propofol infusion is one of the options for someone who is having continuous seizures (status epileptics). It is NOT a pain medication. To get this med, they must be intubated or are the process of being intubated
Why we love it: it works quickly and wears off quickly, allowing us to get a quick neuro assessment. You can detect changes quickly, which is essential.
Interesting fact: they were attempting to use it for executions, but the manufacturer refused to supply it for that need
You must frequently change the tubing (usually every 12 hours)
You must pause it to complete a neuro assessment (usually only a few minutes needed to get the assessment)
Work with your dietician to ensure your enteral feeding formula is appropriate. If you are weaning it or increasing it significantly, they may need to change it. Lots of calories!
Weight based, make sure an accurate weight is in the chart
Watch for hypotension and oversedation
If a patient is getting this for status, make sure you know if they want you to pause it for assessments (most likely not) – make sure there’s an order
Always flush the line – never pause and leave for a while.. it will clot your line!
Titrate to clinical response – don’t just coast. Back off if you need to, increase if you need to.
Mannitol is an osmotic diuretic given to decrease ICP. It doesn’t cross BBB. You increase the plasma osmolality to pull fluid off the brain and out of the body. It increases intravascular volume (pulls fluid into the vessels) and therefore cardiac output.
Interesting fact: it’s actually a sugar alcohol also used in the food industry. It’s a naturally occurring substance found in marine algae and mushrooms.
Make sure your serial labs are ordered: q6hr BMPs most likely
Holding parameters! Make sure you have an order or know when the MD wants to be notified
Serum sodium: typically around greater than 160 (normal = 135-145)
You want to drive the sodium up to remove fluid, but not TOO much
Serum osmolality: typically greater than 320 (normal = 275-295)
Can cause renal failure because of intra-renal vasoconstriction and intravascular volume depletion
Increases CO so watch patients with CHF
Administer through a filter set or draw up with filter needle
If the vial is crystalized, send back to pharmacy to re-warm
Hypertonic Saline (3%)
Used to treat hyponatremia and cerebral edema.
Interesting fact: hyponatremia is the most common electrolyte imbalance
Basically it is salt water. Some docs will use this, some will use mannitol for increased cerebral edema. Evidence is not super awesome about if one is much better than the other.
Probably will need a line
Use judgment.. mild hyponatremia with only one dose.. talk with doc
Watch for a rapid increase in sodium. Shouldn’t rise more than 8-12 mmol/L. in 24 hours. Otherwise central pontine myelinolysis can occur.
Severe damage of the myelin sheaths of the nerve cells in the brainstem. A BIG deal. They can become paralyzed and die. Extent of damage depends on how many axons get damaged.
Need more in-depth neuro info? Check out the Neuro Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like essential neuroanatomy and disease processes, primary and secondary injury, neuro nursing report, meds, time management, mastering the neuro assessment, and more!
Disclaimer: this is a short and sweet explanation of a nursing assessment of an unconscious neuro patient.
References are included at the end with supplemental information.
Always refer to your hospital’s policies and procedures to guide your practice.
This post contains affiliate links.
I was a neuro ICU nurse for four years and worked with some amazing neuro ICU nurses, neurologists, neurosurgeons, and physician assistants. Below are some of the tips I’ve learned along the way!
Education for the family is critical
Before you even touch the patient, let’s chat education.
Let the family know about painful stimuli before you perform it. It can be pretty shocking for someone to see this, so please warn people beforehand.
Another thing that’s really important is to educate them about the importance of the frequent neurological assessments. Family members frequently want their unconscious loved one to do as much as possible (squeeze their hand, raise a finger, wiggle toes, etc.). This is a normal desire. They want them to do well. However, it’s critical that the family allows their loved one to rest between assessments. I’ve just finished bathing, turning, and assessing a patient who needs to rest until I come back in 2 hours to assess them all over again… and before I walk out of the room I start to hear someone scream, “COME ON SWEETIE, SHOW ME HOW YOU CNA SQUEEZE MY HAND!” Please let them know how essential it is for the patient to save their minimal energy for your assessments.
Encourage and educate them about the importance of maximizing rest between assessments because these assessments. This is essential because when changes in brain occur, they are evident in the assessments, not vital signs.
There are lots of beeps and buzzes in the neuro ICU. Educate them about monitors, equipment, and when to worry. Some don’t realize that most of the equipment is connected to a monitor at the nurse’s station and will put on their call light with every beep (which would mean A LOT of call lights!). Some will freak out with each beep, and some will even try to get the beeping to stop by themselves and press buttons they shouldn’t press. Proactively educate.
Unconscious neuro patient assessment tips
Here are some essential neuro ICU assessment tips!
Pause sedation! You must pause sedation for each assessment unless an order tells you not to, otherwise you cannot accurately assess their neurological status
Do your assessment the same way every single time – like your golf swing or how you would shoot a basketball… there should be a very specific routine you go through
Look at CTs and MRIs and compare them to diagnosis
Change in level of consciousness is usually the earliest reliable indication of a change in intercranial pressure (ICP)
Vital signs / pupillary changes are LATE. If you’re just watching vitals and checking pupils, you’re missing something and your intervention will be too late.
Do your first neuro assessment with the off-going nurse to compare
Temperature can profoundly affect your assessment and increase ICP
For each degree increase, the normal metabolic demand is increased by 10%. They increase cerebral edema and infarction!
Temp changes does not typically signify a change in the neuro injury, but requires prompt intervention
Keeping the head of bed at 30 degrees is ideal, unless contraindicated. This keeps head midline, promotes venous return, which decreases ICP. However, make sure this isn’t contraindicated in your patient before implementing
Avoid shivering and agitation, as this also increases ICP. Notify the MD if you’re noting either of these, as they’ll likely order something to decrease it.
Don’t try to interpret your assessment in your documentation, just write what you see (so don’t write “seizure”, write what you’ve observed specifically, like “rhythmic twitching”)
Know your acceptable forms of pain:
Sternal pressure – not rub
Nail bed – can elicit a spinal reflex and be reproduced in a brain dead patient.. I only do this if I’m not getting a response
How to go through your neuro ICU patient assessment
Alright, now that you’ve gone through some basic tips, let’s go through a systematic way to approach assessing an unconscious neuro patient.
Look at vent – are they breathing over the vent before you stimulate them? What’s their respiratory pattern?
Look at them before you touch them – are they making any movements? (Remember, your sedation is paused at this point.) Is this movement purposeful? Are they going for the ventilator, scratching themselves, picking at bed linen, and so forth? Does their face look symmetrical? Note their hemodynamics before you start getting them all riled up.
Level of consciousness – this is super important, people!
Awake / alert: do I really need to explain 😉
Confused: disoriented, agitation, poor memory
Lethargic: awakens, but takes some effort and is kind of cloudy when they wake up
Obtunded: needs repeated stimulation but falls back asleep
Stuperous: minimal movements, pain or vigorous stimulation needed
Comatose: no response to anything at all, not even pain
Eyes, eyes baby
See if they’ll open them by themselves (“Sir, can you open your eyes for me?”)
If they will follow that command, see if you can get them to look in all four quadrants (look up here, down
here, over here, etc.)
Walk from one side of the bed to the other, see if they’ll follow you
If cannot open eyes, do so for them and note that
Close them frequently for them during the assessment
Check pupils for size, shape, level of reactivity (brisk, prompt, sluggish, nonreactive, hippus).
Check blink to threat reflex by pretending you’re going to poke them in the eye, but don’t!
If blink isn’t present, check corneal reflex by using cotton or saline
Oculocephalic reflex/Doll’s Eyes: briskly move head with eyes open. If eyes stay fixed, that indicates loss of brainstem.
I always do this one with the doc, I’m not so great at telling this unless it’s painfully obviously
Cough and gag reflex
Perform oral care, then touch back of throat with oral care kit and observe
Suction patient to elicit cough reflex, note facial response to further assess facial symmetry
Can they follow commands?
“Grip my hand, show me two fingers, give me a thumbs up, wiggle your toes”
Must be repeatable and consistent
Educate family about reflexive movement
Assess all 4 extremities for commands
If no commands.. must elicit pain
See beginning for acceptable forms
Use your pain stimuli on each arm
Progression from best to worst..
Follows commands (yay!)
Localized pain: attempts to stop painful stimulus
Withdraws from pain: pulls away from stimulus
Flexion: flexes arm, note how far (midabdomen, nips), legs will extend
Extension: you’ll know this when you see it! Some will extend and then flex, legs will extend
No movement/response to pain at all (most ominous)
Plantar stroke – we do not want to see their greater toe fan
Lift hand and drop. Rapid drop = coma, slow drop = consciousness
Bend knees; put heels on bed and release
External rotation and drop = coma
Slow extension to bed = consciousness
Video demonstration of the above assessment
As part of a short series of videos, I performed a demo of an unconscious neuro patient on my husband. Here is the video!
More neuro resources
Need more in-depth neuro info? Check out the Neuro Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like essential neuroanatomy and disease processes, primary and secondary injury, neuro nursing report, meds, time management, mastering the neuro assessment, and more!