Day number five of Inktober is my first that I’ve liked at least one thing I’ve created! We have four hens that make it easy for me to do “chicken” I watched our silly, very domesticated ladies walk around the yard all day. They are New Hampshire Reds and we love them! Easiest and sort of favorite pets we own!

I like the pencil sketch best but the cartoony pen one complies with the challenge. Ink not my medium. Lol.

Spellbound—maybe not so much

I know this is a challenge and supposed to be forcing me to practice so that I can improve but I’ve yet to draw anything I like yet…lol. Futility.

But I’m trying and sticking to ink which has been hard especially as I’ve forgotten everything but my sharpie lately.

Disney Conference for Four

We have recently returned from our annual (at least) venture to the land of childhood. I have a conference for my continuing medical education that I like to go to in Orlando that just so happens to be held in Disney World.

The conference is great, casual and refreshing

I primarily woke with pediatrics but like to keep my hand in with family medicine plus there is a lot of overlap with adolescents.

I use Skin, Bones, Hearts and Private Parts for CME. It is exactly that. Dermatology and Msk have been my favorite this time. Last year it was Cards/Urgent Care and Dermatology. There have been different topics and speakers every year that I have come.

Coranado Springs is where we’ve stayed and where the conference is hosted. It’s great. The only other conference I’ve attended was an NPACE conference in Boston and while we loved Boston, especially in October, the conference felt long and a little stiff. I did learn a lot but it was just less fun. They also did not have speakers and topics listed very far in advance.

This year there’s a lot of construction going on at Coronado but I think the visit has still been a good one.

We usually get about an hour or so for lunch so I met the hubby and the girls who of course came to Disney with momma and made a vacation out of it. The pool is awesome and we had a great lunch at just the little pool bar (the restaurants inside the resort are good as well they just tend to get crowded and the weather was nice.

I feel like I get my money’s worth at this conference. They allow you to get the savings from the conference at the hotel a few days before after the conference. It’s a good value. Especially with the early bird discount. My family enjoys the stay with me, and being on Disney property has its perks as well—you don’t have to drive, you can easily get most whatever you need without having to get back in your car.

I have not received anything from SBHPP conference or the like I am just giving my opinion.

Feel free to ask me any questions about the conference or any previous one I’ve attended.

A Short Guide to Breastfeeding Part 2

Challenges Part 2
     While it may not be the only reason, sometimes something in YOUR diet is causing the baby to not tolerate your breastmilk as well as expected. This can lead to excessive gassiness, fussiness, poor weight gain, mucous and even blood in stools with more severe cases. This is a great article with symptoms by Le Leche League. If your baby has these symptoms it does not mean you have to stop nursing your baby (although in rare cases this may be true) but it does mean your diet will need to change. There are many examples of elimination diets out there but you can find the one I recommend here.
     The long and the short of it is you eliminate all but basics for several days or until the baby is asymptomatic and then, just as when starting solids, you slowly reintroduce things one by one until you find the culprit. It works well if done correctly and its a miserable first few days. [I know by experience because my Lil Bit is intolerant of tomatoes and still to this day has a miserable gut for several days when she manages to digest one.]
(My own breastmilk-mustached little one)
Nursing Strike
Every breastfeeding infant is different and therefore every experience nursing can be different as well. I cannot tell you the number of times I’ve had a mom come into my office in tears having difficulty breastfeeding, even those with babies 2, 3 or 6! Nursing strikes happen but the child and course of said strike will determine the length of the strike and the method for getting through it.
Most infant strikes are due to one of three things:
  • Age (developmental stage)
  • Personality (busy-bee or curious baby versus laid-back)
  • Health status (teething, upper respiratory infections or head cold)
Teething and colds can cause nasal congestion (stuffy nose) making it more difficult for babies to latch therefore time and saline with bulb syringe nasal suctioning before feedings may help. Age is a factor for those easily distracted as they begin to explore the world around them more and more. Finding places free from distractions will be helpful with this particular situation. Depending on your child’s age the nursing strike with older infants may be more of self-lead weaning. Personality as cause for nursing strike generally speaks for itself. Some children are far too precocious and independent to nurse as long as others.
So far we’ve addressed the who, what, how but not the when. As in, when do I stop nursing? To this I respond to my patients: how long do you want to nurse? My job is to help mommies meet their goals. The recommendations generally point to at least 6 months for optimal nutrition and up to 1 year of age with supplemental foods added.
If your infant is still small (under 6 months) switch out his least favorite nursing feeds first (generally this tends to be not just after waking, prior to nap or bedtime) with a bottle of expressed breast milk or formula appropriate for age (follow your primary care provider’s recommendations). Another thing I tell moms to do is to have a support person (dad, partner, grandparent) give the non-breastfeeds, slowly weaning for both baby and mom’s safety.  Don’t invest in several of one bottle but rather buy a few different types in order to save you some grief as your infant may not take to a certain brand/shape.
Once your child is older they can use a soft-tipped sippy cup in lieu of a bottle. Most infants are generally going to less and less feedings of their own accord by this time. If you are truly struggling it may not be a bad idea to discuss your case one-on-one with your lactation consult or primary care provider as they know you and your infant better than this blog post.
I hope you have found some comfort or instruction in this short guide. I more than welcome any other future suggestions and would love to hear your stories, triumphs and tribulations with breastfeeding. Please feel free to comment below.

Everyone knows we face many challenges as we go through our journey breastfeeding our babies. To keep this short I will address a few of the more common challenges that I have encountered both myself and in practice


A Short Guide to Breastfeeding Part 1

New to breastfeeding or looking for help with challenges? Want to be a better provider for your patients and their families? Look no further!
We all know that breast is best (human milk for human babies), however, let me just go ahead with a disclaimer that I tell my own patients who are struggling or have conflicting reasons both medical and personal–if you are feeding your baby with formula and  both of you are happy and healthy, you are doing the right thing. I will never belittle a mother or parent for doing what you feel is best for you and your family as long as it is safe and you and your child are healthy.
Moving on…
A Little About Breastfeeding and Why It’s Considered “Best”
So what’s the big deal with breastmilk? The CDC (Center for Disease Control), WHO (World Health Organization), and AAP (American Academy of Pediatrics) all have guideline recommendations in for why we should breastfeed our babies. It’s great for baby AND MOM (physically and emotionally)! It’s great for disease prevention. Hell if you want to get down to the nitty gritty of things, because it does so much good it reduces money spent on healthcare. I’m not going to list all of the things it helps prevent (which when you look at the reports they make it seem like it is prevention rather than formula causing problems but let us not go there…) because I said I would make this a SHORT guide.
(Pic courtesy of
Getting Started 
Pregnant? Planning on getting pregnant? Rather or not you think you want to breastfeed or bottle feed (or a mixture of the two) it never hurts to get more information!
  • Take a class!
    • Many local hospitals and Le Leche League chapters hold free to low-cost breastfeeding classes
  • Read a book!
    • My personal favorite is The Womanly Art of Breastfeeding which I had read cover-to-cover (borrowed) as a floor nurse prior to having children because nursing school had taught me very little about breastfeeding and I wanted to be a great resource for my patients. I bought the book when I became pregnant and read it again, passing it own to a friend shortly after my daughter was weaned.
    • Breastfeeding Made Simple I didn’t care for this one quite as much and basically skimmed it. That being said if your library only carries this one or you want more than one choice, it’s not a bad one and is in fact a bestseller on amazon.
  • Ask Someone! Talk with your friends who have kids, talk with your mom (and then back all of this up with one of the above)
  • Keep in mind everyone’s experiences are different and that even amongst themselves, each baby can be different!
Vitamins and Supplementations
Vitamin D
Long gone are the days for the majority of the civilized world where women continue to work in fields or roam nomadically across the plains to scavenge for foods with their babies strapped or carried with them. In fact we know sunburns are detrimental for our skin in the long run and thus we avoid or use sunblock which prevent production of vitamin D.  Humans need sun for vitamin D production and we need vitamin D for bone growth (and new studies suggest that it may help innate immunity and play a role in prevention of diseases such as diabetes and certain cancers).  As such mom nor their babies tend to make enough vitamin D. Therefore the AAP and CDC recommendations include either baby receiving supplementation of 400IU daily or mom taking an extra 5000 to 6000IU daily so that baby receives enough through breastmilk.  Commercial formulas contain vitamin D so supplementation is not generally needed.
Breastmilk does not readily contain a large amount of iron and healthy, full-term (born at 38 weeks or later) infants generally have used up their stores by 6 months of age and iron-fortified infant cereal, other iron containing foods or supplementation with iron drops/vitamins are recommended.
Breastfeeding is not easy for everyone and can hold many challenges. I once had a physician friend tell me that some women were just meant to be wet nurses. She said this semi-jokingly but also as reassurance to me that I was not the only working mom struggling to keep my supply up (it did not help I was not only working full-time but in graduate school for the entire stent as well). That being said here are some of the things that I have not only found helpful for myself but have in my practice also found helpful for my patients and their babies.
Latch difficulties
This often becomes difficult for my patients before they ever even reach my office. Once the baby is born, most hospitals are now trying to follow recommendations that babies go straight to mom’s chest. This helps regulation baby’s body temperature, blood glucose levels and helps with breastfeeding initiation but not all moms have a baby that just latches on with ease, nor do all mom have “optimal breastfeeding nipples” or even the nursing staff with knowledge about breastfeeding.
  • Asking for a lactation consult is always a big help as well as either forgoing modesty or kicking all of your family out of your room until you and baby get things figured out. If a lactation consult isn’t available and you and baby aren’t quite getting the hang of it consider
  • Nipple shield
  • Pumping for about 5 mins and then trying to attach baby
  • Multiple positions (football/rugby hold is great for new babies, craddle-hold, side-lying, australian crawl or biological hold)

breastfeeding positions

(Pic courtesty of
Don’t be afraid to do what you need to do!
Decreased Supply
There are many many reasons for decreasing supply:
  • hormonal (starting menses, thryoid issues, pregnancy)
  • medications (antihistamines)
  • poor-latch
  • pumping (not all women respond well to the pump)
  • stress
  • infrequent feeding and/or bottle feeding (ladies our breasts are supply-and-demand responders)
so what can we do about it?
  • more frequent feedings/pumping sessions
  • stop medications causing decrease if possible (consult your physician!!)
  • seek help with latch issues
  • make pumping as comfortable as possible with a good pump and a good-fitting flange, warm blanket, cup of tea, comfie spot in which to pump, relaxing music, an item that smells like baby
  • de-stress! (i.e. with postnatal yoga, getting a massage, seeking medical care if your are over-anxious or depressed)
  • take a nursing holiday (you and baby cuddle skin-to-skin all day and nurse on demand while taking it easy and eating well, taking in plenty of fluids)
  • consider supplements (Mother’s Milk Tea, Fenugreek capsules (it may take up to 3200mg of fenugreek for some women to see results but start low and go slow, avoid it altogether if you have thyroid or pituitary issues))
Just a reminder that this a SHORT, very abbreviated guide. I hope you enjoy and find it helpful and informative. The second part will explore more challenges and weaning.

MSN/FNP Graduate School Prep: Part One

I found it hard at first to look back and remember graduate school and specific things about practicum and studying for boards even though it has not been THAT long ago. Call it PTSD or repression of traumatizing events, haha. I’m only half-joking and I think mine was so rough because I was either pregnant or with a newborn for the majority of it and working full-time (yikes) and still vaguely unsure of how I survived. I made the most of my practicums and was lucky enough to have had a lot of family support for help with the baby. My husband took on an extra part-time job so that I could go part-time for the final portion of my clinicals. It was still exhausting and I wanted to go to bed every night by 9pm if not earlier.

I had to document each encounter in our school’s system using IC9 codes (now ICD10) and CPT codes for all the visits. As annoyingly time consuming as this was, it was worth it in the end because I had exact numbers for the different types of patients I had seen and procedures completed. The reason that this practice was so valuable was because it made that information readily available when applying for hospital privileges. I was lucky in that my school provided a program from which an excel sheet could be extracted but if yours does not I would recommend keeping track as it may save you time in the long run.


funny ICD10

(Image courtesy of heathcarenews I believe…I can’t remember where it came from so forgive me, I had saved as a joke but thought it to be funny)


EMRs suck. That’s the long and the short of it but they are also a necessity for the majority of practices. They slow you down compared with paper but very few practices are eligible to use that anymore. Fortunately, most nurses have already had some experience with EMR (electronic medical records) prior to grad school and therefore have an idea of the layout. Ours is in the form of (very detailed) SOAP notes, which from what I gather, is the current standard for most NP programs. So if you haven’t already familiarized yourself with this format then go ahead and start.

Soap note

Another extremely free and valuable resource I used was Evernote (for both desktop and my phone). It made it easy for me to do studying on the go during small downtimes I had (waiting for an appointment, riding in the car, etc). I would copy and paste study plans there especially as I was getting ready to study for boards. I was not aware of how valuable this resource would be when first starting, but had I known, I would have started using it with each didactic course at the beginning of my program. You can arrange different notebooks for each course like I did then have individual “notes” for each topic.


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When I was ready to study for boards (and pre-boards we had to pass a comprehensive final at my school which I found to be more difficult than boards) I took practice tests then focused on my weaker areas or areas I was less familiar with in my past clinical experiences.


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I just used the free version and have never tried the paid for version but it might be worth looking into if you find you need more storage space. I believe the free is now 60mb limit. However, I have many notebooks and it has not yelled at me yet to upgrade. Again, I have yet to receive anything from any company unless I otherwise mention so this is all just personal opinion.

As silly as it may sound, set yourself out a study plan and make it realistic. Most people in graduate school have the added weight of balancing family time, work, etc. Where are you going to squeeze in textbook reading assignments? Papers? Research? I did this for boards and wish I had created such a schedule for papers and didactic work. I’m pretty “Type A” anyway but I was forced to be even more so with all that was going on with life. Trying to fit in some study-time when I had a sitter on non-work days or when my hubby was going to be home was difficult and required preparation. We were on a tight budget especially at the end when I had to drop down to part-time so I went to Target, bought a large dry-erase calendar and skinny dry-erase markers and color coded our schedules. Even the Moose’s schedule (my hubby) who was begrudgingly standing in the kitchen acting put-off as I asked him day after day what his plans were so that I could schedule everything.

I try to save helpful things I find on Pinterest if you want to follow me or any of my boards you may find them helpful. I’m under Everyday Empress and have a board E2NP where I try to put helpful advice/sites as well as posts if you’ve missed any. Recently I have been adding equipment I have found helpful (some that I just like 🙂

Until next time!




I have had my mommy blog for some time nowbut I’ve always wanted to have my own NP blog. Both to connect with other NPs out there and to provide folks out there with some general thoughts and information that I find helpful. Again, second to there being non-self-governing persons who refuse to take responsibility for their own decisions/actions please see my disclaimer.

And no…I’m not bitter but anyone who’s worked as a health care professional can understand where I’m coming from; I work especially hard at trying to help patients take care of themselves but many just want a quick fix. How many times have you had patients leave your office angrily because you recommended only over-the-counter medicines for symptom relief and explained antibiotics wouldn’t help their cold? I can’t say it’s always the patient but rather our cultures expectations for working. I don’t know about my friends in other countries but here in America, at least the portion I live in, you generally are looked down upon if you call out sick. (Those same coworkers also get angry when they contract your plague.)

It’s not all bad here, we don’t have to wait months and months for urgent treatments, but the focus of our healthcare system has moved less and less away from patient self-care and responsibility and more towards customer service which is borderline disastrous. Don’t believe me? See here and here . It makes absolute sense that someone would rather have a pint of craft beer, filet mignon and truffle fries with a chocolate cake slice as big as your face over a 9-inch dinner plate with arugula and microgreens. Hell, I’d have a hard time saying no to the first but when your cholesterol is 300, you sit at a desk for 8-10 hours a day and Netflix marathon every night afterwards, you definitely need the later or you’re likely investing in a heart disease savings account with pretty terrible returns. However, how immediately satisfied do you think a person is going to be when you try to tell them they need to limit or avoid their favorite foods? It’s like showing a preschooler candy and saying, “See this? I know you want it, but you can’t have it!” Cue tantrum. Patients are not happy about being told they are the problem no matter how nicely you tell them and babying them and letting them lead the same old lifestyle earns you a gold star and them an early grave. 

I’m not a big fan of standardizing testing and scores in general but that’s another matter. I love my patients and I want them to be healthy and if you are also a provider I hope you feel the same way and keep your chin up and join me in bracing ourselves until the whole business blows over while waiting to come up with a way to fix it. 

I also hope you join me in celebrating my successes and failures (let’s call them life lessons) as I move forward in my career and try to make the world a tad bit better one patient at a time.

Until then, ciao!