A classmate and I are having a debate on whether or not nurses use nursing diagnosis in the real world. I say yes, he says no. I know that one of the hospitals that we clinical at does indeed use them on a regular basis, but he believes that they are one of few. Thoughts?

I have yet to see any nursing diagnoses used at any of my clinical sites!

How my teacher explained it, is that it is not that they use them per se in the "real" world, they are teaching us to frame our thinking a certain way. Meaning, I can walk into a patient's room, assess the situation and think in terms of "risk for impaired skin integrity" - and because of the care plans I have done, I just know what some interventions are.

You may not be seeing them because the RN is responsible for their creation and you may not have access to that data or know where to look. CMS (people who write checks for Medicare and Medicaid) and other insurors want a care plan for every patient. You cannot plan unless you know what you are planning for - so nursing diagnoses are required. Ask at your clinical sites where the data would be located. Our EMR does it automatically, depending on how the RN completes the assessment. The RN has to "approve" what the program comes up with, and is free to edit.

They are there and nursing diagnosis are used. You just don't have access to it in an active chart as a student. The nursing diagnosis typically used aren't NANDA FYI.

We have full access to the charts. I've seen lists that look somewhat reminiscent of nursing diagnoses, but definitively not NANDA, so I guess that must be it? On the floor it's typically something like Risk for DVT with a number goal, and how well the goal was met. I'm fairly certain the nurses aren't coming up with the list, though. Not at all how we're taught to do things!

Really depends on what EMR system your site is using. Most of the stuff is pre-planned. You generally don't have time to sit down and write out an entire care plan like you do in nursing school. Ain't nobody got time for that.

I really think they are valuable and we should cultivate them in our thinking about the patient care needs and not lose that habit. I do use them in the documentation my agency uses - it is SOAPE format. The ND is the Assessment piece.

Even if they do not actually "use them" in their charting they are used to assess patient priority. Nursing diagnosis' are very important, and are there to help you assess all of your patient problems and then prioritize them. I always hear people complain about care plans but I think that it would be very difficult for a nurse to "assess and prioritize in their head" without the history of care plans.

We use them in nursing care plans on a daily basis.