Doctor vs Nurse

  1. I work in a nsg skilled facility and rehab at the same time. Our medical director always orders continue to monitor when I report something to him. One time I reported an extremely high blood glucose level of our hospice pt.he just told me what should he do since she's hospice! As much as I want to talk back on him that we should still treat the resident even if they are hospice I only suggested to increase her insulin. And as soon as I got the order I hung up on him.

    Yesterday, I learned from my co-workers that he was infuriated that I logged a pt condition and stating the pt med that might have had a side effect.

    I also wrote down that a couple of pt was having early s/sx of flu.

    Oh yeah, one of our resident also has an incredibly audible wheezing inspiratory and expiratory but he doesnt want the resident be on a hospital so he ordered a stat cxr. The patient has an atelectasis. He ordered an antibiotic med. My gut feeling is telling me to send that resident into the hospital but I cannot make him give me an approval to send her out.

    How can I speak with my DON about this matter?
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    About anne919

    Joined: Dec '11; Posts: 138; Likes: 20


  3. by   emily5547
    As far as discussing this matter with your DON (which was your ultimate question), I should think expressing that you have concerns about specific patients' treatments, facility protocols, MD orders/lack-thereof/interactions, and you wish to better understand rationale, etc., making sure you're open to feedback and want to work within the scope of your practice and the rules of the facility, while ensuring your patients receive appropriate care, should be a good starting point for a discussion. The only reason I'm actually compelled to comment is to actually implore you to never document a diagnosis. As long as you're not an NP, you should not be diagnosing medical conditions. You are assessing patients. You can document all the s/sx of influenza that you've assessed, but it is not in our scope to develop that diagnosis. I know it's sometimes frightening to work in a tertiary care setting, but I'm not necessarily convinced that the patient with atelectasis requires acute inpatient hospitalization. Are they satting well? Are they in distress? Activity tolerance? Appetite? Have they responded at all to the abx? Are they A&O enough to teach deep breathing techniques, etc.? I would take your concerns to another nurse (charge, DON, experienced colleague) and use it as a possible teaching moment. Of course, patient safety is your very valid concern, and you're there with the patient, you have to go with your gut sometimes and what you're observing - I just get the sense that perhaps you could also be over-reacting and you are definitely going to want to avoid documenting new diagnoses in the future.
  4. by   applewhitern
    I agree with Emily that it sounds like you are diagnosing patients. You can document an assessment of your findings, and what you did about any abnormal findings, but you cannot diagnose the patient.
  5. by   jadelpn
    There is a difference between hospice and comfort care. If the patient was comfort care only, then perhaps I would clarify if FBS still needed to be done. Or if the patient is hospice and still in the early stages and was getting all their meds still, I would ask for an increased sliding scale.

    As far as the atelectisis, I would call your supervisor, state the what the chest x-ray showed, relay your concern on the condition of the patient, and let the nursing supervisor take it up with the MD. Documenting same. (Should you have to call looking for orders asking for a timeline on the observation--if no improvement in 4 hours, should I call you for further orders or what you would like me to do to ease this patient's distress?)

    All in all I would call your supervisor or ask your charge to deal with the MD if you really feel as if the patient needs transport and the MD is not on board with that.
  6. by   Lpn1226
    I work in a LTC/ skilled nursing facility and it is not uncommon for someone with atelectasis to be given an atb and monitored. Now if they are in distress that is one thing but coughing, fever, wheezes you can deal with at the facility. And I agree with the other posters don't document diagnosis' I've been told u can get in trouble for that. You can describe symptoms but not diagnose.
  7. by   anne919
    I dont document diagnosis but rather the s/sx only.

    All I can say is that I am no doctor and I am not really good with assessment but when im really in doubt with pt circulation I will take abrupt actions rather than have a code in the floor.
  8. by   eatmysoxRN
    In the hospital setting I've seen nurses document "pt showing sx of flu. Will request blah blah from md..." personally I always document and inform the md of any sx or distress and never document a suspected dx. I will tell the doc verbally and ask for it but I don't document that.
  9. by   anne919
    What I do is just log the objective assessments into the dr's log book. If the pt's lab shows impending dhn and pt refuses oral hydration and the urine's color is abnormal and going to anuria that is when I call the md.

    He even said before that the pt is hospice what else does he need to do. I know that hospice and dnr are no code but it does not mean do not treat them!

    Now he told my supervisor that he wont answer any of my page any longer. So when there is a real code it would be my problem.

    I dont know if I am bashing his ego as md or he's got other factor.
  10. by   ♪♫ in my ♥
    Personally, I'd speak to the MD about your questions rather than going straight to the DON. Your concerns may be assuaged or they may be magnified. Either way, I'd want to start with the doc to be sure that I'm not missing something. You can always go up the ladder if you decide that's warranted but generally, an experienced MD has specific reasons for the course of treatment that they're following and you may come off looking very silly if you go around him.
  11. by   anne919
    That md is just really difficult to deal with.

    More residents are now having s/sx of flu that they now have confusions because of dob. Yet he doesn't want to order anything.

    My pt desat yesterday and guess what he said send the pt out if I really think the pt needs it coz he wont give me an order for oxygen! I told him that i initiated an oxygen at 2 liters per minute to have my pt's spo2 to go up and help her with wheezzing and labored breathing. She had became cold and clammy. And after few minutes my other co-worker walked to me telling me that the md ordered her to check with my pt and assess how is the pt doing in room air and with o2.

    The supervisor came back from break and guess what she had told me the pt is cold and clammy because of the room temp. I dont know what did that supervisor is thinking the room temp is normal room temp, not hot or cold. One of my co-workers left the room because he cannot confine his laugh of the supervisor's comment.

    It is a realization that I need to move to another workplace.
  12. by   psu_213
    Unfortunately, I'm not sure what all your abbreviations mean (such as dob), so it makes it a bit more difficult to answer. I would avoid communicating that a resident has "flu symptoms." The flu has many symptoms and many of those symptoms are also symptoms of something else. Report to the doctor exactly what symptoms a resident has (for example "short of breath with a cough and a fever"). From there, he is the one who has to decide how to work it up and he decides what medical diagnosis to query.
  13. by   BrandonLPN
    My thoughts: how high was the hyperglycemic resident? Was he actively dying? Was he eating? If the doctor didn't order an extra insulin dose, I'm sure he had a reason. Don't be afraid to ask why, but don't approach it in a confrontational way. I've learned a lot by asking the doctor rationales behind his orders.

    As for the resident with wheezes and atelactisis, why do you want to send him to the hospital? Is he febrile? The CXR didn't necessarily indicate pneumonia, right? And the resident is on ABX. So why put him throughout the ordeal of going to the ER? He can be monitored and treated safely in place. I mean, atelactisis and wheezing may just indicate the resident needs a neb treatment and to do some cough/deep breathing exercises to expand the lungs. Unless I'm missing something you seem to be jumping the gun a little.
  14. by   anne919
    The pt with atelectasis is not responsing with the neb treatment and she was supposed to be discharged on the next day but she started wheezing.

    To describe this fully: His inital order was just robitussin. I lied to him that the pt is having difficulty of breathing even though the resident says that everything if fine cause my gut feeling is telling me that it isnt just a regular wheezing since the resident has inspiratory and expiratory wheezing.and so he ordered a stat chest xray and antibiotic. Then the xray revealed that the pt has atelectasis. Case rested with that one cause the doctor does not seem to care to treat if the pt is being discharged or hospice or no code.

    And yes, I basically describe every pt sibjective and objective symptoms with nsg observations. I dont medically diagnose.

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