my D.O.N. frightens me

LVN_2_DOC · Aug 17, 2004

several different thoughts are being expressed that i feel the need to address and elaborate on. in doing so i will refrain from including any parties web/blog name in my following diatribe.

the nurse has provided a much more accurate account of what the situation was when she decided to modify the patients diet.

the nurse wrote: "he had lung cancer.he had esophageal varicesis. he was an emaciated man who drank pepsi and ate cake. he said he couldn't swallow anything but that. he ate oatmeal, enjoyed it, had no problem with it.i did speak to my rcc when she arrived."

this is different than the original part of the post "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"

this shows a rational for her actions and that she was reporting a change in the patient's condition. i would expect that somewere in this equation a doctor was going to be notified. i also note that this dysphagia has been ongoing or at least from the history it sounds like it might not have been an acute change.

it was also written: "i am offended by your comment that i am not a team player and took the ball and began to play without the team. have you ever worked in a long term facility with only yourself, a few aides and a supervisor?"

i will apologize for offending you. but i will say that i would do it all over again if you make independent decisions without following them up and reporting changes in patient status that caused you to make the changes. i will also answer your question about the long-term facility question. yes i did a few temp jobs in these type of facilities, and with the conditions that you speak of. i limited this aspect of nursing career and did not venture back once entering medical school.

too many people are running away with the neurologic possibilities of cva/tia as my stated cause of this dysphagia. i only offered those as part of a differential that needed to be examined and ruled out by the doctor a pa or an apn.

now getting back to my original statement about the need to report changes in patient status. i would have agreed with the don if this were the issue at hand. (ie the patients dysphagia was recent in presentation, and no doctor was called, and the rcc was not informed) it sounds like the nurse in the original stem was trying to pass the info up the chain, and i am sure that a doctor would have been called.

now lets think about why if this was a dramatic change in patient status a doctor should have been informed. with the history of lung ca, and esophageal varices we need to consider tumor invasion loco regionally or how about mets to the brain? let's also worry about enlarging varices that could be treated with banding, injection, cautery or surgery? this was my original intent in citing the need to inform the doctor of changes in patient status even something as simple as swallowing difficulty. i only threw in the cva/tia as one point on the differential diagnosis that a doctor would consider. just to give you an example of what i am trying to explain here is a basic list of what a should be considered when thinking about dysphagia:

first is oropharyngeal or esophageal

oropharyngeal dysphagia:

cerebrovascular accident, parkinson disease, brain stem tumors, degenerative diseases, such as als, multiple sclerosis (ms),huntington disease, poliomyelitis, syphilis, peripheral neuropathy, myasthenia gravis, polymyositis, dermatomyositis, muscular dystrophy (myotonic dystrophy, oculopharyngeal dystrophy) cricopharyngeal achalasia, obstructive lesions, such as tumors, inflammatory masses, zenker diverticulum, esophageal webs, extrinsic structural lesions, anterior mediastinal masses, and cervical spondylosis

esophageal dysphagia:

achalasia, spastic motor disorders, such as diffuse esophageal spasm, hypertensive lower esophageal sphincter, nutcracker esophagus scleroderma, obstructive lesions, such as tumors, strictures, lower esophageal rings (schatzki ring), esophageal webs, foreign bodies,vascular compression, mediastinal masses

it has been pointed out with poor fashion that i have done the following."insult your peers by admonishing their actions; your actions and implications are insulting, arrogant, disrespectful and presumptuous."

i would like to think that each and every nurse or doctor who views himself or herself as a patient advocate wants to provide the best care for their charges. i realize that at times this might force a person to review how they practice and hopefully develop more effective and safer patient practices. i believe that the patient is more important than the care provider's feelings. i have in the past and i will again in future standup and be first in line to protect the patient's rights and welfare in the face of unreasoning antagonism.

Dixiedi1 · Aug 18, 2004

you are it nit-picking.

it is assumed the nurse did her job. we all try our best to do our job so there was no reason for any of us to assume she did not know what she was doing. the point of the whole thread seems to have escaped you.

we are not talking about the need to change the diet but rather the dons apparent need to "take it out" on someone.

please, you have much to share here, don't ruin it by reading too much into posts.

it just sounds so much like you need to point out how much more you know now than you did when you were an lpn. we are happy for you and we know lpns do not know nearly as much as a doc should know but that does not mean the lpn is not capable of performing job duties and thinking beyond basics. (changing the diet as she did is not beyond the scope of practice.)

with this i will leave this thread because it is far too heated for what it is. hope to see you around here in the future.

several different thoughts are being expressed that i feel the need to address and elaborate on. in doing so i will refrain from including any parties web/blog name in my following diatribe.

the nurse has provided a much more accurate account of what the situation was when she decided to modify the patients diet.
the nurse wrote: "he had lung cancer.he had esophageal varicesis. he was an emaciated man who drank pepsi and ate cake. he said he couldn't swallow anything but that. he ate oatmeal, enjoyed it, had no problem with it.i did speak to my rcc when she arrived."
this is different than the original part of the post "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"
this shows a rational for her actions and that she was reporting a change in the patient's condition. i would expect that somewere in this equation a doctor was going to be notified. i also note that this dysphagia has been ongoing or at least from the history it sounds like it might not have been an acute change.
it was also written: "i am offended by your comment that i am not a team player and took the ball and began to play without the team. have you ever worked in a long term facility with only yourself, a few aides and a supervisor?"
i will apologize for offending you. but i will say that i would do it all over again if you make independent decisions without following them up and reporting changes in patient status that caused you to make the changes. i will also answer your question about the long-term facility question. yes i did a few temp jobs in these type of facilities, and with the conditions that you speak of. i limited this aspect of nursing career and did not venture back once entering medical school.
too many people are running away with the neurologic possibilities of cva/tia as my stated cause of this dysphagia. i only offered those as part of a differential that needed to be examined and ruled out by the doctor a pa or an apn.
now getting back to my original statement about the need to report changes in patient status. i would have agreed with the don if this were the issue at hand. (ie the patients dysphagia was recent in presentation, and no doctor was called, and the rcc was not informed) it sounds like the nurse in the original stem was trying to pass the info up the chain, and i am sure that a doctor would have been called.
now lets think about why if this was a dramatic change in patient status a doctor should have been informed. with the history of lung ca, and esophageal varices we need to consider tumor invasion loco regionally or how about mets to the brain? let's also worry about enlarging varices that could be treated with banding, injection, cautery or surgery? this was my original intent in citing the need to inform the doctor of changes in patient status even something as simple as swallowing difficulty. i only threw in the cva/tia as one point on the differential diagnosis that a doctor would consider. just to give you an example of what i am trying to explain here is a basic list of what a should be considered when thinking about dysphagia:
first is oropharyngeal or esophageal
oropharyngeal dysphagia:
cerebrovascular accident, parkinson disease, brain stem tumors, degenerative diseases, such as als, multiple sclerosis (ms),huntington disease, poliomyelitis, syphilis, peripheral neuropathy, myasthenia gravis, polymyositis, dermatomyositis, muscular dystrophy (myotonic dystrophy, oculopharyngeal dystrophy) cricopharyngeal achalasia, obstructive lesions, such as tumors, inflammatory masses, zenker diverticulum, esophageal webs, extrinsic structural lesions, anterior mediastinal masses, and cervical spondylosis
esophageal dysphagia:
achalasia, spastic motor disorders, such as diffuse esophageal spasm, hypertensive lower esophageal sphincter, nutcracker esophagus scleroderma, obstructive lesions, such as tumors, strictures, lower esophageal rings (schatzki ring), esophageal webs, foreign bodies,vascular compression, mediastinal masses
it has been pointed out with poor fashion that i have done the following."insult your peers by admonishing their actions; your actions and implications are insulting, arrogant, disrespectful and presumptuous."
i would like to think that each and every nurse or doctor who views himself or herself as a patient advocate wants to provide the best care for their charges. i realize that at times this might force a person to review how they practice and hopefully develop more effective and safer patient practices. i believe that the patient is more important than the care provider's feelings. i have in the past and i will again in future standup and be first in line to protect the patient's rights and welfare in the face of unreasoning antagonism.

yasmina · Aug 19, 2004

I work in a nursing facilty as a MDS/Quality Coordinator and have been a RN since 1978.

We can 'what if' about the cause of a resident's dysphagia until we are blue in the face.

The bottom line, in my opinion, is that nurses can tell when a resident is having an acute problem. LPN's and CNA's are intimately involved with these individuals. In the real world, doctors are not notified every time a resident has a complaint.

Today I had a resident mention to me that he 'just didn't feel right.' He was sweating a bit. I questioned him, and determined he needed to have his vitals taken, blood sugar...and get somebody to him that really knew him.

That was the LPN on duty. She assessed him, I assessed him...we decided to observe. Yes, he could have been having an onset of many, many, many problems.

Realistically: in long term care, the nurse makes a lot of independent decisions. If the nurse is constantly contacting the doctor, the doctor gets upset. I don't see the nurses calling doctors for everything. In long term care, the LPN is in a position of great responsibility (well deserved).

I came in the middle of this forum. How long had the resident c/o dysphagia? What is his history?

If I notified doctors of residents complaints, I would do very little else but be on the phone to the doctors.

The other thing...in long term care, things are much slower paced. Yes, a resident could have a problem ensuing. The nurse might observe for a while. In long term care, I don't see health care practitioners jumping every time there is a complaint.

I kind of need to go look at the original message conveyed. I just think that this thread has gotten really mean! Really, doesn't matter that much who the clinician is: doctor, nurse, APN....It is clinical judgement. Just because someone has a higher degree doesn't make them better than another clinician. In long term care, again, the primary nurse (typically an LPN), along with the CNA are so important and intricate to care. A APN or MD who visits every month is usually really detached from the picture.

I will go back to the original thread. There is too much argueing here! All health care professionals are important.

yasmina · Aug 19, 2004

I re read the beginning of this ensuing nurse practice dilemma. The person who spoke of the study taking a few weeks (perhaps) is correct.

The nurse who downgraded the diet, in my opinion, was prudent.

If the DON was concerned, it would have been prudent to quietly discuss the situation.

Sounds like the nurse involved is a GEM! And, could get a job just about anywhere.

Yes, we all want to cover our behinds. However, in the real world, I don't think what she did was at all negative. May have taken her many hours to notify the doctor. She may have ended up on the phone with a doctor who didn't even know the resident.

Nurses make a lot of judgement calls. That is why there are verbal orders that are signed 48 hours later. Perhaps she should have been quietly told to get an order for the diet change....and if in this instance there was significant concern over dysphagia, contact the doctor. But, writing up the nurse who used her judgement? No. Good nurses who care are hard to find.

The nurse who comes to work impaired, steals, can't document at all, cannot calculate rates/doses...these are the kinds of nurses to get written up!

debbiemig · Oct 14, 2004

Here's an update on my DON who I mentioned was MEAN! She was fired!!!!!!!!!!!!!Came to work drunk! Not one person was sorry to see her go! Debbie

i agree with angie o., debbie.
you sound like an excellent nurse and are clearly wasting your talents there.
you deserve much better.
wishing you all things good.
leslie

FranEMTnurse, CNA, LPN, EMT-I · Oct 14, 2004

Here's an update on my DON who I mentioned was MEAN! She was fired!!!!!!!!!!!!!Came to work drunk! Not one person was sorry to see her go! Debbie

Wonderful. You have now been freed. However, I do hope that lady will seek some help. Won't the BON require that before she can practice again?

virmm1, LPN · Oct 14, 2004

Wow,what a thread, I work in LTC and I would and have done the same thing in the same situation. Better to be written up( not tht I would have signed the thing.) rather than have the pt choke to death or get aspiration pneumonia and die. :angryfire

I'm glad you stayed at your job. Those residents need nurses like you. Keep up the good work.

debj1 · Nov 23, 2004

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?

If you do your job to the best of your ability, and still feel like this, then approach her and talk to her about something small. In doing this you will find out if she is a nice DON or a dragon lady. I've worked with both kinds, and usually the dragon lady will slip up and you will outlast her position. Sometimes they make you think they are like that to keep control of their building. If she is a new DON she's probably testing her power over her workers, and it will end when she figures out that she has that power.

lyceeboo · Nov 23, 2004

The nurse who comes to work impaired, steals, can't document at all, cannot calculate rates/doses...these are the kinds of nurses to get written up!

I'd want you as my nurse anyday, Debbiemig!

BearyPrivate · Jun 1, 2008

You must realize the DON's job is much tougher than the floor nurse:twocents:. She has alot of responsibility and has to deal with corporate, state, family, administration, dietary, therapy issues for each patient day in and day out:eek:. Her job is to make sure your job is completed properly so her butt does not get chewed from her higher ups. Maybe if you ask her if she has problems with your work or you personally, you can find out how she feels. This worked for me and now my DON and I get along alot better and it did calm my fear that she didn't want me gone:yeah:. I know our job is tough, but try putting yourself in her shoes. You know she has so much stress. she has to make sure everything possible is being done to ensure state doesn't come down hard on petty little things. Try talking with her about your anxiety and fears. It couldn't hurt:wink2:. Who knows maybe you can be a help to ease her stress as well. :saint:

gt4everpn, BSN, RN · Jun 4, 2008

my DON is friendly but I've met a DON with attitude, no-one scares me, I do my work the right way whether or not anyone's watching! Ive only been a nurse for a year but Ive learned not to be intimidated, its the experience, it helps with confidence!!

pagandeva2000, LPN · Jun 4, 2008

You must realize the DON's job is much tougher than the floor nurse:twocents:. She has alot of responsibility and has to deal with corporate, state, family, administration, dietary, therapy issues for each patient day in and day out:eek:. Her job is to make sure your job is completed properly so her butt does not get chewed from her higher ups. Maybe if you ask her if she has problems with your work or you personally, you can find out how she feels. This worked for me and now my DON and I get along alot better and it did calm my fear that she didn't want me gone:yeah:. I know our job is tough, but try putting yourself in her shoes. You know she has so much stress. she has to make sure everything possible is being done to ensure state doesn't come down hard on petty little things. Try talking with her about your anxiety and fears. It couldn't hurt:wink2:. Who knows maybe you can be a help to ease her stress as well.

I can definitely see how the job of the powers that be can be extremely stressful. And, we can't determine how we, personally, would handle things if we were in their shoes. I have assessed myself thoroughly and can say that I would not do well under that short of pressure, because I think it would change who I really am internally.

What I have seen, though, is that being one of the higher-ups does not automatically make one a better person; they bring alot of their personal issues and personality traits. Once grimey, always grimey for many. Add a screwed up attitude with a great deal of stress and bingo, a disaster waiting to happen.