my D.O.N. frightens me

[tiroka03]

I do a good job, and don't have anything to fear. But, when I see the D.O.N. walk in the building, I feel afraid. I wonder, What does she think I did wrong? Will I be fired today? Lately there has been a lot of people getting warnings for little things, and I suppose big things as well. I have tried always to do my best, but just the thought of her frightens me. It always feels like she is looking down her nose at me. I suppose she can sense my unease. Do any of you feel like I do?

[LVN_2_DOC]

In reading the above conversation I have to disagree that the LPN was within rights to change the PT's diet. I will not go into the differential of neurological causes of dysphagia. Provided that was what the pt had. Lets not even consider things like esophageal fistulas, webbing, cancer, varices, and many others. I also want to say that I understand the LPN's frustrations at wanting to help. But I have been there in the past and decided that I needed to put up or shut up. Hence I have taken the time to go back to school. Yes I think the nursing experience "helps" as an Intern but there are times it clutters up the way I need to think as a doctor. Hey I may know that a patient has CHF, but that is only a clinical diagnosis with a knee jerk reaction of (O2, Lasix, CXR, BMP, BNP, Foley). I still have to consider all of the reasons for a patient to progress to CHF and treat at that level. To solve the problem. Well enough of that all of you all have a good day:smokin:

[leslie :-D]

ok.

next time, in spite of the pt's c/o dysphagia, we'll just keep him on a house diet and possibly choke.

for crying out loud, the patient wanted the puree as evidenced by his request for lunch. he said it was much easier to swallow.

the nurse used very prudent judgment and had she not downgraded it according to her assessment, the liabilities would have been much higher.

and a nurse does not need an order to downgrade a diet until the patient can get a speech eval.

but you DO need an order to upgrade and is something i would never do w/o such an order.

this nurse acted prudently and again, would hate to think on the implications of her not intervening.

leslie

[Dixiedi1]

ok.

next time, in spite of the pt's c/o dysphagia, we'll just keep him on a house diet and possibly choke.

for crying out loud, the patient wanted the puree as evidenced by his request for lunch. he said it was much easier to swallow.

the nurse used very prudent judgment and had she not downgraded it according to her assessment, the liabilities would have been much higher.

and a nurse does not need an order to downgrade a diet until the patient can get a speech eval.

but you DO need an order to upgrade and is something i would never do w/o such an order.

this nurse acted prudently and again, would hate to think on the implications of her not intervening.

leslie

Excellent response!

[Hellllllo Nurse, BSN, RN]

In LTC facilities where I've worked, even RNs are not supposed to change a diet order without a doc's order.

Of course it happens, but not officially.

[LVN_2_DOC]

i have quotes from the following earle58 and debbiemig in my reply

"to be specific, i had a resident that was admitted over the weekend i was off, who had difficulty swallowing. we spoke and he agreed to try a pureed diet. i ordered it, he ate it, did well and said to give it to him for lunch. i ordered it"

what i see here is a patient admit that came in over the weekend and that this nurse did not do the original h&pe.

the patient has difficulty swallowing and the nurse has not reported this....."any one able to think possibility of cva or tia" but said nurse chose to change the diet. not once did this nurse mention that she attempted to let any one else know about this patient.

now to address the following from member earle58

"for crying out loud, the patient wanted the puree as evidenced by his request for lunch. he said it was much easier to swallow"

i have to disagree with that the patient wanted the puree, but i will admit that the patient was talked into the puree.

now i am glad that we can agree that this patient has a swallowing problem. but let's not get all-emotional about it. in fact the question should be why does the patient have a swallowing problem and is it something that is new onset something that a doctor say an eent could fix. but as long as a doctor never evaluates this patient we may be missing some pathology that is killing the patient...hey i know as a doctor i am the biggest patient advocate in the patient receiving the best care.

i would also like to comment on the following statement by earle58

"next time, in spite of the pt's c/o dysphagia, we'll just keep him on a house diet and possibly choke."

i never said that changing the diet was not the correct thing to do. heck it might have been more prudent to place the patient on npo and go back and review the chart and call the doctor to inform him if this was an acute change. but remember what the nurse in question (debbiemig) had written.

i hadn't had ime to speak with the dr as of that time. ( he would have agreed to anything i said, he trusts my judgement).

i am sure that depending on the facts and the dr's h&pe, he might have agreed to the dietary change. but the simply fact is debbiemig had not contacted the doctor nor had debbiemig passed this information along.

hey it is a team effort and debbiemig just took the ball and started to play without the team.

[leslie :-D]

you know lvn,

you sound very new in your nsg. career.

i highly suggest you do not go around insulting other nurses as if they know nothing and you know it all.

in any admission, an md has to be contacted to let them know they have a new patient at the facility. so the nurse would be speaking with the md either way.

the md has 48 hours to admit a patient.

the diet they were on in the hospital is not necessarily the same diet they will be on in the facility.

other than reported c/o swallowing, there are far more obvious symptoms of a stroke.

whatever the etiology of dysphagia is, any nurse should assess the patient's ability to swallow or not. it is far safer to downgrade and is indeed a judgement call. not so for an upgrade. it would be the nurse's responsibility to report to the doctor, their findings.

no matter what you seem to think you know from a book, you've much to learn.

it wouldn't hurt you to learn from the many pros on this board.

peace,

leslie

[LVN_2_DOC]

earle58

Well earle58 I will give you that I am new to this board.....I had a 4th year Medical student tell me about it.

But lets get a little info straight. I worked as a nurse "LVN" from 92 till 97 full time in the hospital (med surg/neuro/ortho/icu/ccu/rehab). When I decided that I wanted to make decisions for the type of care that my patients needed I went back to school. I worked to part time in home health and hospice while in undergrad until I was accepted to medical school. I have completed that phase of my education and I am currently in my residency.

Now lets discusses the following:

Yes there could be more ominous signs of a stroke than dysphagia but it could also be the only sign (you lost there). Heck the patient could have been experiencing a TIA (do you know the signs). The patient could also have had many other problems that are neurologically or mechanically based that are causing this dysphagia..

But the simple facts remain:

I have not insulted any on this web site: You are merely being inflammatory with your commentary. (Please tone it down and stick to the facts)

The laws regarding when a doctor must see a patient are different in your state.

In mine a physician H&PE is to be on the chart in 24hrs. (it might be caught up in dictation but it should be done)

Now lets examine a few simple points you made:

You admit that "whatever the etiology of dysphagia is, any nurse should assess the patient's ability to swallow or not. it is far safer to downgrade and is indeed a judgement call. not so for an upgrade. it would be the nurse's responsibility to report to the doctor, their findings."

This is what I was commenting on to start with. The nurse in question made a choice to change the doctors admit orders and did not confer/ report / or let the doctor know about a change in patient status. She also did not state the she had informed the charge nurse of her changes in patient care. That is not being a good nurse and reporting a change in patient status. Some pathology that was reversible might be missed and become irreversible.

I am truly worried about the way you put "whatever the etiology".

That is exactly why the doctor should be informed. The doctor will never have a chance to find out the "whatever the etiology" if he or she is never contacted.

You wrote: "no matter what you seem to think you know from a book, you've much to learn."

I do agree that I have much to learn.

I hope that I will be learning the rest of my life.

I also know that I learn from my mistakes the question I have is do you?

You also wrote: " it wouldn't hurt you to learn from the many pros on this board."

You are correct there is much about patient changes and needs that a nurse has to tell to the doctor.

I know how much I rely on changes in patient progress when I ask a nurse "how did mr/mrs/miss/ Z do last night:"

But please be my guest and let teach me something that is useful and not just inflammatory.

[UM Review RN, ASN, RN]

I read this whole thread with mild interest, then increasing disbelief.

It looks to me like Debbiemig's facility policy clashed with common sense.

I work a Progressive Care unit. Both our LPNs and RNs are required to do a Swallow Screen and an NIHSS to assess swallowing ability for patients with a TIA/Stroke dx.

In my years of experience, if a patient c/o difficulty swallowing due to a TIA, I have NEVER seen dysphagia as the only symptom, so the scenario you present regarding TIAs, LVN, is highly unlikely.

It looks to us like you're trying to throw your weight around, LVN, because an LPN of 30 years made a nursing judgment that would be made by any medical professional given that circumstance.

I also feel the need to educate you on the fact that aspiration problems also carry a set of s/s--or not.

Most of our stroke patients are "silent aspirators," and report no problem swallowing, even though it is patently obvious to us nurses that their voice quality is wet, their swallowing is delayed, and/or their cough reflex is impaired.

I am confident that had the OP noticed any of those s/s or others that precluded the patient from eating at all, she would've placed the patient in question on NPO status (please take note: that is a diet change) and contacted the doc immediately for follow-up.

There's an old saying that holds true here: if it ain't broke, don't fix it. This experienced nurse reported no other obvious problems with the patient except comfort and preference--therefore, it was a patient request.

In other words, she could quite literally have gotten the diet changed because the patient refused the regular diet, and in that case, was certainly within the bounds of nursing judgment to make that call.

In response to the OP, I used to feel apprehensive too, when I saw the DON come into the building. Then I got to know her as a person as well as an authority figure. That helped, but she also took the time to get to know me. Looks like you have to make the first move here. Just smile and act friendly and she'll come around.

[P_RN, ADN, RN]

Please refrain from attacking other member's in their postings. Debate the ISSUE and not the person. Please review the TOS

https://allnurses.com/forums/showthread.php?t=31788

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Let me add that I have seen many, many times an order for diet as desired/diet as tolerated and progress. To assume the nurse was taking on more than she should is not correct. We have the description by the nurse who was there. None of us were.

[CHATSDALE]

In every LTF that i have worked changed the texture of the diet, esp the downward alteration. ie regular to chopped, chopped to pureed, or placing thickener in fluid to ease ingestion was an option of the nurse on duty...in many facilities the md sees resident q 60 days..the nurse (usually an lpn) has to make many of the day to day decisions this nurse who changed diet was right and should have written strong protest on WRITE UP

[FranEMTnurse, CNA, LPN, EMT-I]

phew....

first you come on this bb and insult your peers by admonishing their actions;

your actions and implications are insulting, arrogant, disrespectful and presumptuous.

you've clearly insulted a nurse with over 30 years of experience.

do you expect me to qualify myself to you???? regarding what I know about strokes, tia's or whatever else you choose to question???

listen lady,

if you think for one minute that you are going to succeed at whatever path you choose, you best take that attitude of yours and do some intricate evaluation.

and btw, i DO intend to see what or if there is anything that can be done about your demeanor.

leslie

That's my girl. She's doin' me proud once more.

[debbiemig]

THANK YOU!!!!!!!!!!!!!!!Leslie! My sentiments exactly! I thank you ALL for your responses whether I agree with you or not. You have all given me lots to ponder! Debbiemig

ok.

next time, in spite of the pt's c/o dysphagia, we'll just keep him on a house diet and possibly choke.

for crying out loud, the patient wanted the puree as evidenced by his request for lunch. he said it was much easier to swallow.

the nurse used very prudent judgment and had she not downgraded it according to her assessment, the liabilities would have been much higher.

and a nurse does not need an order to downgrade a diet until the patient can get a speech eval.

but you DO need an order to upgrade and is something i would never do w/o such an order.

this nurse acted prudently and again, would hate to think on the implications of her not intervening.

leslie