Robbie’s Four Rules of Professional Practice
I received a call from Dr. Gloria Rose, my former professor at Prairie View A&M University College of Nursing, asking me to be the keynote speaker at the Pinning and Hooding Ceremony on May 9, 2018. After taking a breath, I accepted the offer and stated, “Yes, I am honored to do it.” As soon as I got off the phone with Dr. Rose, I called my mother and she was so proud of me.
As a nurse practitioner (NP), my work experience includes opening a clinic and managing house calls, as well as serving in homeless shelters, skilled nursing facilities, pediatrics, family practice, community, personal care homes, private homes, weight management, pain management, and the Redi-Clinic. Throughout my sixteen years of practice, I have developed four rules which have assisted me to accomplish success. The following rules have supported my differential diagnoses and plan of care for clients.
Rule 1. Get a
Good History
One of my favorite jobs was working at the homeless shelter. I recall a case that continues to stay with me to this day. The medical assistant presented: “He is here to have his string cut from his chest. The NP before you just cuts it and then he returns again when it gets too long.” I was thinking what is going on with string cutting from the chest.
As the man is sitting on the examination table, I asked how he is doing and right away he states, “I just need you to clip this string and then I will be okay. That’s what they do, clip it.” He removes his shirt and right away I see the healed surgical incision down the middle of his chest, but in the center is dark blue string protruding from a very small hole.
“When did you have the open-heart surgery, sir?”
“I think it has been about three years,” he replied.
“Have you been getting the string cut for the past three years?”
“Yes, ma’am,” he replies.
“I am not going to cut the string today. This is suture string that is hanging out of your chest from the open-heart surgery. We do not have radiology services here. I want to get all of the string out for good.”
Then, I secured the string with gauze and taped it to his chest. I arranged for him to go to a special procedures clinic. I provided cab vouchers and informed him to leave now. A couple of days later, the man returned. He was smiling. He stated that he had a gift for me. He gave me an envelope. I opened it. It was filled with suture string. Then he said, “Thank you! You solved the problem!”
Rule 2. Take Your Time
I learned this in graduate school. I saw a young female who presented with missed periods, vomiting, and fatigue. I was focused on her vomiting, and I was in a hurry. I left the room. I failed! Turned out she was pregnant. They say that you learn from your mistakes. I learned that day to always “take my time.”
Rule 3. Be Professional At All Times
At the homeless shelter, I saw a man and asked him how he was doing. “I am not doing well. The doctor gave me this medication for my blood pressure. Oh man! I keep peeing from left to right. As a matter of fact, I got to pee right now.” I reviewed the chart. The medication was hydrochlorothiazide. It is a diuretic which causes frequent urination. I changed the medication to lisinopril to treat his blood pressure and instructed the man to keep a log of his BP readings by going to the CVS around the corner. I gave him pens and a pad and instructed him to return in two weeks for follow-up. When he returned, I was off. My collaborating physician followed up with the patient. He called my supervisor upset that I changed the medication he prescribed. Upon my return to work my colleagues stated, “Robbie, you are in trouble.” I held my tongue. I remained calm and quiet. As I reviewed the chart there was a copy of his blood pressure log, which showed improvement in his blood pressure since taking the lisinopril. This man is homeless and does not have the comfort of a home with a restroom. He has to locate a public restroom to relieve himself. In my professional opinion, changing the medication was the best treatment for him and improved his quality of life.
Rule 4. Go With Your Gut Feeling
During a house call visit the client stated she had a sore and cannot understand how it got there. She reported, “at first I had pain at that same area.” (gut feeling) “Then this sore appeared. Went to the emergency room (ER) and was told that it was an insect bite.”
“Okay, let me see the sore; lift up your shirt.” I saw a fluid filled lesion on an erythematous base. “You have shingles.”
She looked at me, “are you sure?”
“Yes, I am.”
“But the doctor at the ER said it was an insect bite. You are a nurse.”
“I am a nurse practitioner. I can contact your primary care provider (PCP) to prescribe the medication to decrease the severity of the shingles.” She was still not convinced. “Okay, let’s take a picture with your cell phone and then you can send it to your PCP.” As I was leaving, the doctor’s office called and verified the diagnosis. Pain is a symptom that occurs before the lesion appears.
My four rules of practice have provided me with a solid foundation and are the framework of my practice. Every day, I use my four rules of practice and the outcomes are immeasurable. It’s great to know when you have improved the client’s quality of life. This is the greatest satisfaction of all to achieve as a NP.
