Real World NP

You're seeing a patient for a preoperative evaluation before an upcoming surgery. The surgeon has requested some testing and documentation—but how do you determine what your patient actually needs before their procedure?

Which patients need additional cardiovascular evaluation? When should you use RCRI or DASI? Do you need to order an ECG, chest X-ray, or routine labs? And how do you document your assessment without saying the patient is "cleared" for surgery?

In this updated episode of Real World NP, we're walking through a practical approach to the preoperative evaluation for noncardiac surgery in primary care, including updated cardiovascular risk assessment recommendations and how to apply them during an actual patient visit.

What You'll Learn:

• What your role is during a preoperative evaluation
• How to assess surgical risk and identify reasons to pause before surgery
• Using RCRI, ACS NSQIP, and DASI to assess cardiovascular risk and functional capacity
• What to include in the preoperative history and physical exam
• Assessing chronic conditions and pulmonary risk before surgery
• When preoperative labs, ECGs, and imaging are indicated
• Medication considerations before surgery, including anticoagulants, diabetes medications, and SGLT2 inhibitors
• What to document and communicate to the surgical and anesthesia teams

Timestamps

00:00 – Introduction

01:32 – Your role in the preoperative evaluation

02:13 – Assessing surgical risk

03:04 – Reasons to pause before surgery

03:58 – Cardiovascular risk assessment: RCRI and ACS NSQIP

04:45 – Functional capacity and DASI

05:24 – Preoperative history and chronic conditions

06:56 – Pulmonary risk assessment

07:25 – Physical exam and selective testing

08:25 – Perioperative medication considerations

09:37 – Documenting the preoperative evaluation

Resources Mentioned:

Preoperative Evaluation Cheat Sheet: A quick-reference guide to surgical risk, cardiovascular assessment, functional capacity, testing, and documentation. Get your copy at www.realworldnp.com/binder

For a full transcript and conversation chapters, visit the blog: https://www.realworldnp.com/blog/preop-exam-nurse-practitioner

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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Starting insulin in type 2 diabetes can feel intimidating—especially when you're a new NP seeing a patient with an A1C of 13% or 14% and wondering: Does this patient need insulin? Can I safely manage them outpatient? And how much insulin should I actually start?

In this episode, I walk through a practical approach to starting basal insulin in adults with type 2 diabetes, including updates from the 2026 ADA and AACE guidelines.

We'll cover when insulin is appropriate, how to calculate a starting dose, how to titrate using fasting blood glucose, and what to do when fasting glucose is at goal but A1C remains elevated.

We'll also talk about CGM, preventing hypoglycemia, and making insulin initiation manageable for patients—because you don't have to solve everything in one visit, but you do need to make sure your patient can safely manage their treatment at home.

For a full transcript and conversation chapters, visit the blog: www.realworldnp.com/blog/starting-insulin-type-2-diabetes

Need a Quick Insulin Reference?

The Digital NP Binder includes an updated Starting Insulin in Type 2 Diabetes cheat sheet with dosing, titration, monitoring, and treatment considerations for primary care. https://www.realworldnp.com/binder

Want More Support with Diabetes Management?

The Diabetes Management in Primary Care course covers medication selection, treatment adjustments, insulin therapy, diabetes monitoring, and more. https://www.realworldnp.com/diabetes

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

A patient with COPD comes in with worsening cough, sputum, and shortness of breath. Is this actually a COPD exacerbation? Can you safely treat them outpatient? And do they need antibiotics?

In this episode, I walk through a practical approach to evaluating and treating COPD exacerbations in primary care, including updates from the 2025–2026 GOLD guidelines.

We’ll talk through how to rule out other causes of worsening respiratory symptoms, assess exacerbation severity, decide when a patient needs a higher level of care, and choose appropriate treatment—including bronchodilators, prednisone, and antibiotics.

TIMESTAMPS:

00:00 COPD exacerbations: 2025–2026 update

01:30 Confirming COPD + the patient's baseline

02:19 COPD exacerbation or something else?

04:26 Assessing severity + when to escalate care

07:20 COPD exacerbation treatment: inhalers + prednisone

08:00 When do you need antibiotics?

10:45 Follow-up + reassessing long-term COPD treatment

For a full transcript, resources mentioned in this episode, and conversation chapters, visit the blog: www.realworldnp.com/blog/copd-exacerbation-new-nurse-practitioner

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

COPD guidelines have changed—and if you’re managing COPD in primary care, there are a few updates worth knowing.

In this episode, I walk through how to approach a patient with COPD at a routine visit, especially when you’re seeing them for the first time or inheriting their care from another provider.

We’ll cover how to confirm the diagnosis with spirometry, how to think about GOLD 1–4 alongside the ABE assessment, and how the mMRC and CAT scores fit into your assessment. We’ll also talk about alpha-1 antitrypsin deficiency testing, blood eosinophils and inhaled corticosteroids, initial inhaler therapy, and what to monitor at follow-up.

I also walk through the pieces of COPD management beyond medications—including smoking cessation, vaccinations, exercise and nutrition, pulmonary rehabilitation, and management of comorbidities.

In this episode:

00:00 – Introduction + COPD guideline updates

01:03 – Approaching COPD management in primary care

01:53 – Confirming COPD with spirometry and FEV1/FVC

03:01 – Pre-COPD and PRISm

03:53 – GOLD 1–4 and the ABE assessment

05:12 – Using the mMRC and CAT scores

06:23 – What to assess at a COPD follow-up visit

07:50 – Alpha-1 antitrypsin deficiency testing

08:26 – Blood eosinophils and inhaled corticosteroids

09:37 – COPD management beyond inhalers

11:15 – Pulmonary rehabilitation and comorbidities

11:37 – SABA, SAMA, LABA, LAMA, and ICS

12:21 – Initial COPD treatment by GOLD ABE group

13:50 – Initial treatment for Groups A and B

14:35 – COPD follow-up and spirometry

15:04 – Chest imaging and lung cancer screening

15:46 – When to refer to pulmonology

COPD cheat sheet + Digital NP Binder: realworldnp.com/binder

For a full transcript and conversation chapters, visit the blog: https://www.realworldnp.com/blog/copd-management

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

What does a GI specialist wish primary care providers knew before sending a referral?

In this episode, I’m joined by family nurse practitioner Paige Sosebee, who has worked in gastroenterology since 2019 at a large academic medical center. We talk through some of the most common GI concerns we see in primary care—and what happens on the other side of the referral.

Paige shares practical pearls on H. pylori testing and treatment, GERD and PPI trials, evaluating abnormal liver tests, celiac testing, chronic constipation, SIBO and intestinal methanogen overgrowth (IMO), and how primary care can make GI referrals more useful for both the specialist and the patient.

We also talk about something that comes up constantly for newer NPs: How much of this am I actually supposed to manage myself, and when is it time to ask a specialist for help?

In this episode, we cover:

• H. pylori testing, treatment, and common pitfalls
• GERD management and when to consider EGD
• Elevated liver enzymes and what to do before referring
• Celiac testing and the importance of testing before going gluten-free
• Chronic constipation, red flags, and initial management
• SIBO and intestinal methanogen overgrowth (IMO)
• How to make GI referrals more useful—and when they’re truly urgent

Timestamps:

00:00 – Introduction

02:19 – Meet GI specialist Paige Sosebee, FNP

04:31 – H. pylori testing, treatment & referrals

13:20 – GERD, PPIs & when to consider endoscopy

20:06 – Alginate therapy for GERD

22:31 – Elevated liver tests & GI referrals

24:51 – Elevated alkaline phosphatase & imaging

30:00 – Celiac disease testing

41:10 – Chronic constipation

46:00 – SIBO & intestinal methanogen overgrowth (IMO)

52:50 – When to refer to a GI specialist

56:00 – Clinical resources for primary care NPs

For a full transcript and conversation chapters, visit the blog: http://www.realworldnp.com/blog/gi-specialist

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

When should you refer a patient with CKD to nephrology—and what should you do before they get there?

In this episode, I’m joined by nephrologist and medical educator Dr. Rachel Hilburg to talk through the questions that come up all the time in primary care: interpreting proteinuria and hematuria, deciding when a nephrology referral is urgent, what labs and imaging to order before referral, and what we can actually do to slow CKD progression.

We also talk about the Kidney Failure Risk Equation, cystatin C, kidney-protective medications, preparing patients for dialysis and transplant, caring for patients already on dialysis, and a practical approach to hyponatremia.

Want to feel more confident managing CKD in primary care?

The Chronic Kidney Disease Management Course walks you through CKD diagnosis, monitoring, treatment, slowing disease progression, and when to refer to nephrology.

CKD Management Course: https://www.realworldnp.com/ckd 

Or get the CKD course as part of the Chronic Care Bundle, which also includes diabetes, hypertension, and kidney lab interpretation.

Chronic Care Bundle: https://www.realworldnp.com/chronic-care-series-bundle 

For a full transcript and conversation chapters, visit the blog www.realworldnp.com/blog/nephrologist

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

Valvular heart disease often presents gradually— often slowly becoming more fatigued, less active, or more short of breath over time— making it easy for symptoms to be attributed to aging or deconditioning. In this episode, Liz Rohr sits down with structural heart nurse practitioner Christy Cantey, FNP, to discuss how primary care clinicians can recognize subtle symptoms of valve disease, know when an echocardiogram is appropriate, and understand what happens after a patient is referred to a structural heart program.

They also discuss modern transcatheter valve procedures—including TAVR and TEER—and how these minimally invasive treatments have changed outcomes for patients with aortic stenosis and other valvular diseases.

Timestamps

00:00 Meet Christy Cantey, NP

02:02 What Is Structural Heart Disease?

03:22 Understanding Modern Valve Procedures

06:05 Symptoms That Should Raise Concern

07:28 Two Questions That Reveal Functional Decline

08:51 Why Patients Often Don't Realize How Sick They Feel

09:47 The Challenge of Detecting Heart Murmurs

11:09 When to Order an Echocardiogram

12:07 Why Early Referral Matters

15:35 Working With Structural Heart Programs

18:15 What TAVR and Valve Procedures Are Really Like

20:56 Primary Care Follow-Up After Valve Intervention

23:19 Long-Term Monitoring and Annual Echocardiograms

26:17 How to Counsel Patients Who Are Hesitant About Treatment

32:32 Clinical Pearls and Resources for Learning More

For a full transcript and conversation chapters, visit the blog http://www.realworldnp.com/blog/valve-disease-primary-care

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

The PREVENT Risk Calculator is a newer cardiovascular risk assessment tool developed by the American College of Cardiology (ACC) and American Heart Association (AHA). Designed to replace older pooled cohort equations, it provides a more comprehensive estimate of cardiovascular risk, including both atherosclerotic cardiovascular disease (ASCVD) and heart failure risk.

In this episode, Liz Rohr breaks down what the PREVENT calculator is, how to use it in clinical practice, and why it's becoming an increasingly important part of cardiovascular risk assessment in primary care.

Timestamps:

00:00 - Overview of the Prevent Risk Calculator and its significance in cardiovascular risk assessment

00:26 - How the calculator improves risk estimation over previous tools

01:16 - Key inputs needed for the calculator and optional risk-enhancing factors

01:41 - Incorporating additional data like zip code, A1C, and urine albumin

02:07 - Interpreting 10- and 30-year risk results for ASCVD and heart failure

03:02 - Thresholds for hypertension (≥7.5%) and hyperlipidemia risk categories

03:38 - Practical tips for clinicians on using and interpreting the tool

04:06 - Importance of risk-enhancing factors and patient-specific decision-making

04:55 - Limitations of population-based risks and underestimation in young adults

05:52 - Avoiding over-reliance on the calculator and considering the full clinical picture

06:46 - Summary: integrating the Prevent calculator into patient conversations and management pathways 

For a full transcript and conversation chapters, visit the blog https://www.realworldnp.com/blog/prevent-calculator-aha

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

What actually changed in the newest hypertension guidelines—and what should nurse practitioners be doing differently in clinic?

In this episode, Liz Rohr, MSN, FNP-BC, sits down with Dr. Jordy Cohen, nephrologist, hypertension specialist, researcher, and member of the hypertension guideline writing committee, to break down the updates that matter most for primary care.

Rather than reviewing every recommendation, this conversation focuses on the clinical decisions that can make the biggest difference in practice. Dr. Cohen shares practical guidance on medication selection, single-pill combination therapy, resistant hypertension, screening for primary aldosteronism, and evaluating younger patients with elevated blood pressure. The discussion also covers the PREVENT risk calculator, home blood pressure monitoring, white coat hypertension, and common treatment mistakes that can be avoided in everyday clinical practice.

Whether you're learning hypertension management for the first time or updating your approach based on the latest evidence, this episode offers practical strategies you can apply immediately in primary care.

00:00 – Meet Dr. Jordy Cohen and the new hypertension guidelines

02:27 – Biggest changes in the updated guidelines

04:00 – The PREVENT risk calculator explained

07:30 – Managing hypertension in younger adults

11:40 – Secondary hypertension workup and screening pearls

15:20 – Resistant hypertension: What specialists wish primary care would do first

19:20 – When to start one medication vs. combination therapy

22:10 – Choosing first-line antihypertensive medications

25:40 – Hydrochlorothiazide vs. chlorthalidone vs. indapamide

29:45 – Primary aldosteronism: Who should be screened?

36:00 – Why PRN clonidine should be avoided in severe asymptomatic hypertension

41:10 – Home blood pressure monitoring, white coat hypertension, and validated cuffs

49:40 – Microalbuminuria and practical pearls for primary care

If you found this episode helpful, be sure to subscribe to the Real World NP Podcast and share it with a colleague.

Real World NP provides practical, evidence-based continuing education designed specifically for nurse practitioners to bridge the gap between graduate education and real-world practice.

For a full transcript and conversation chapters, visit the blog https://www.realworldnp.com/blog/HTN-updates-2026. 

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.

Urine microalbumin is one of the earliest indicators of kidney damage, but the terminology—and the recommendations—have changed over the past several years.

In this episode, Liz reviews the 2026 updates to urine microalbumin interpretation, including the transition to albuminuria and the urine albumin-to-creatinine ratio (UACR), new hypertension screening recommendations, and practical pearls that every primary care nurse practitioner should know.

Whether you're a new graduate or an experienced NP looking for a refresher, this episode will help you better understand what the test measures, when to order it, and how to avoid some of the most common interpretation pitfalls.

Chapters:

00:00 Introduction to Microalbuminuria

01:38 Understanding Urine Microalbumin Testing

06:44 Clinical Significance of Microalbumin Levels

10:38 Conclusion and Course Invitation

11:40 Introduction to Real WorldNP Podcast

11:40 Exploring Resources for New NPs

The Renal Lab Interpretation course takes a deeper, case-based approach to urine albumin, creatinine, eGFR, electrolyte abnormalities, and common kidney disorders seen in primary care.

We’re doing a LIVE round of the Lab Interpretation Series (which includes the Renal Lab Interpretation Course) starting in August with Live Q&As, learn more https://www.realworldnp.com/live

For a full transcript and conversation chapters, visit the blog https://www.realworldnp.com/blog/microalbuminuria-2026-updates 

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hosted on Acast. See acast.com/privacy for more information.