Nurses don't diagnose! (wanna fight about it?!)

[jjjoy]

OKay I needed a catchy title... let me be more specific now, my argument is two-fold as spelled out below. I appreciate respectful feedback on these thoughts. I don't really want to fight!

#1 Professional nursing care is the professional assessment and management of a patient's (or community's) health conditions/status/indicators. This may or may not include providing medical diagnoses and making medical/surgical treatment decisions.

#2 "Nursing diagnoses" is a confusing misnomer. "Professional nursing assessments" might better reflect the function of these labels.

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With a license, the nurse has the right to make "professional nursing assessments". Thinking of nursing this way, nursing diagnoses actually make sense (except for calling them 'diagnoses'). It's not that only someone with a nursing license can recognize and identify "diarrhea" or "insomnia", it's that only someone with a nursing license is allowed to apply those labels in professional documentation and communication.

A lay person can often correctly conclude if someone has impaired mobility or confusion or the like. A nursing assistant can - and should - recognize many conditions that professional nursing assessment addresses such as confusion and risk for falls. What the lay person and assistant *can't* do is offer "professional nursing assessment" of the condition. In the same way, nurses can - and should - recognize and identify medical conditions even though they may not be qualified to give professional medical diagnoses.

In fact, lay people often assess and manage their own nursing and medical needs. Many lay people diagnose their own medical conditions and implement treatment plans, but if they want a professional opinion, they go to a doctor/NP/PA. Similary, lay people often assess and manage their own nursing needs, but if they want professional assessment and management, then they need a professional nurse!

(I was inspired to elaborate on this after reading NANDA's FAQs about nursing diagnoses.

NANDA International Nursing Diagnosis Frequently Asked Questions

)

[llg, PhD, RN]

There IS a difference between Assessment and Nursing Diagnosis. Yes you do draw conclusions in assessments but Nursing Diagnosis are a certain set of predetermined diagnosis set forth by NANDA. Assessments aid the RN to develop Nursing Diagnosis, Nursing Diagnosis develop and define the Care Plan.

As defined by NANDA

"A nursing diagnosis is used to determine the appropriate plan of care for the patient. The nursing diagnosis drives interventions and patient outcomes, enabling the nurse to develop the patient care plan. Nursing diagnoses also provide a standard nomenclature for use in the Electronic Health Record, enabling clear communication among care team members and the collection of data for continuous improvement in patient care"

Not to be offensive but some posters resumes may be longer.... NANDA was only founded in 82' and Nursing Diagnosis were developed there after to further improve patient outcomes and develop professional Nursing.

Every single professional Nursing organization I have come across recognizes ADPIE as the official Nursing Process. Remember that the profession of Nursing is ever changing as a result of evidence based practice.

The only reason we have gotten into trouble over the term is due to a "Knowledge Deficit" of Nurses and the public at large. Sounds like a great basis for a care plan

I'm not offended ... and I certainly don't want to start a fight ... but I can't let your implication that I am "an old fogey who has not kept up with contempory nursing" go without comment.

I am well aware that ADPIE is the predominant acronym these days. I just don't agree with it. Just because NANDA says something, doesn't make it right. You need to keep in mind that the NANDA folks have built their careers (and personal financial livelihoods) on the NANDA diagnosis schema. They are not an unbiased source of information on these matters. Reading their pronouncements is like reading articles about medications put out by pharmaceutical companies.

A sign of a healthy discipline is the presence of open discussion among its members. I am an experienced nurse scholar who happens to questions some of the work being done by NANDA. That doesn't make me old and out-of-date. It makes me an independent thinker who has not fallen for some of the more dogmatic aspects of the nursing diagnosis movement.

[ivanh3]

To "D" or not to "D"…hah, I couldn’t resist….

Doesn’t matter what you call it, or what letter you give you it., but "assess" and "(nursing) diagnose" are two different and necessary components of the process. I understand the inclination to say that "D" in ADPIE is redundant, but it really is not. First the data must be gathered i.e.assess(which is a verb) and then it must be critically analyzed i.e. "D" or Assessment (which is a noun and the results of the verb) or whatever nomenclature makes you happy. It is possible to draw more than one conclusion from the same data set and therefore have different treatment paths. Naming those conclusions can help in the communication process, and it can help in the "triage" process of determining which "D" would be more important to deal with first. Without using our critical thinking skills the data from assess is just that: data.

I do agree with the OP that the word diagnose is confusing. I think it is because convention and frequent usage (even by nurses) leaves the word "medical" understood. Also, it is confusing because whether or not nurses "medically" diagnose or not, we work with medical diagnoses all day long and are expected to be familiar in their meaning, implication, and use.

You're splitting hairs here, so should they change the name of "Football" because "foot" and "ball" are emphasized when in reality it should be "carry or pass" and "ovoid?"

Yes, because the rest of the world knows that football is a game played with a round ball that is kicked around on the ground....hah...couldn't resist again!

[jjjoy, LPN]

To "D" or not to "D"…hah, I couldn’t resist….

LOL

"assess" and "(nursing) diagnose" are two different and necessary components of the process. I understand the inclination to say that "D" in ADPIE is redundant, but it really is not. First the data must be gathered i.e.assess(which is a verb) and then it must be critically analyzed i.e. "D" or Assessment (which is a noun and the results of the verb) or whatever nomenclature makes you happy. It is possible to draw more than one conclusion from the same data set and therefore have different treatment paths.

I don't see how the 'same data set' can lead to different conclusions in regard to specific nursing diagnoses. I do see that two people with the same medical condition won't necessarily have the same exact set of problems and thus the full set of nursing diagnoses applied to each patient will be different. But each patient also presents a different data set as well.

Can you name a set of circumstances where the nursing diagnoses for a patient who is unsteady on their feet would be something other than risk for falls? How about a set of circumstances where a patient with a wound doesn't get the nursing diagnosis of impaired skin integrity? What circumstances would lead a nurse to NOT give the diagnosis of impaired gas exchange to a patient with COPD?

[jjjoy, LPN]

How does SOAPIE compare to ADPIE?

Subjective Data - Assessment

Objective Data - Assessment

Assessment - Nursing Diagnosis

Plan - Plan

Implement - Implement

Evaluate - Evaluate

Yes or no?

[ivanh3]

I don't see how the 'same data set' can lead to different conclusions in regard to specific nursing diagnoses. I do see that two people with the same medical condition won't necessarily have the same exact set of problems and thus the full set of nursing diagnoses applied to each patient will be different. But each patient also presents a different data set as well.

Can you name a set of circumstances where the nursing diagnoses for a patient who is unsteady on their feet would be something other than risk for falls? How about a set of circumstances where a patient with a wound doesn't get the nursing diagnosis of impaired skin integrity? What circumstances would lead a nurse to NOT give the diagnosis of impaired gas exchange to a patient with COPD?

Those would be correct, but off of the top my head what about about a patient who has been assessed as having weakness? Risk for falls, self care deficit, etc. For your wound patient, how about "risk for infection"?

How does SOAPIE compare to ADPIE?

Subjective Data - Assessment

Objective Data - Assessment

Assessment - Nursing Diagnosis

Plan - Plan

Implement - Implement

Evaluate - Evaluate

Yes or no?

I would say yes. When I started as a paramedic we used SOAP. We combined Plan and Implement. If there were any changes we documented them under the "S" or "O". At my current employer we use PIE (P: problem or focus, I: intervention, and E: evaluate)

[HamsterRN, ADN, RN]

LOL

I don't see how the 'same data set' can lead to different conclusions in regard to specific nursing diagnoses. I do see that two people with the same medical condition won't necessarily have the same exact set of problems and thus the full set of nursing diagnoses applied to each patient will be different. But each patient also presents a different data set as well.

Can you name a set of circumstances where the nursing diagnoses for a patient who is unsteady on their feet would be something other than risk for falls? How about a set of circumstances where a patient with a wound doesn't get the nursing diagnosis of impaired skin integrity? What circumstances would lead a nurse to NOT give the diagnosis of impaired gas exchange to a patient with COPD?

It's true that every patient can fit into Nursing Diagnosis categories, it's not difficult when you use extremely broad, generic categorizations to define patients, the problem is that the interventions need to be patient specific, which is one reason why NANDA nursing diagnoses are being phased out. The purpose of nursing care is to treat patient as individuals, not as broad generalizations.

[HamsterRN, ADN, RN]

A diagnosis is a description of a problem. While NANDA nursing diagnoses are now a thing of the past thanks to the Joint Commission and Patricia Benner, we still describe problems based on our assessments, and if we aren't then we should be. If you believe your job is simply to collect information and pass it on to someone else without evaluating yourself as well, then you are an LPN, not an RN.

For instance, a patient comes in because they stopped taking their lasix because they couldn't afford it, couldn't get to the pharmacy if they had the money, and didn't know to take their extra potassium when they got leg cramps. A Doctor will describe this simply as "CHF exacerbation". Nursing may describe the problem differently, such as "CHF exacerbation due to inability to afford and obtain lasix and lack of education regarding prn potassium." If we're not doing this, how do we know what to do for the patient?

[jjjoy, LPN]

Those would be correct, but off of the top my head what about about a patient who has been assessed as having weakness? Risk for falls, self care deficit, etc. For your wound patient, how about "risk for infection"?

Is there ever a patient with an open wound who *doesn't* have "altered skin integrity"? Of course not. This nursing diagnosis simply puts the assessment into a particular wider category. Pressure ulcer, skin tear, incision - altered skin integrity. The nursing care plan won't depend upon the nursing diagnosis, it will depend upon the specific type of 'alteration' that led to the diagnosis. So what function does 'diagnosis' play in the nursing process there?

Is there ever a patient with an open wound who *doesn't* have "risk for infection"? Of course not. An open wound compromises the body's defense system. No 'critical analysis' there; only one 'conclusion' to reach. Open wound = risk for infection.

[jjjoy, LPN]

A diagnosis is a description of a problem.

Dictionaries reflect how words are used and the definitions I looked up did not define diagnosis as "a description of a problem".

If you believe your job is simply to collect information and pass it on to someone else without evaluating yourself as well.

Doing a thorough assessment includes evaluating the data you're gathering, which nurses most definitely need to do. I don't see how that relates to whether or not nurses 'diagnose' patient conditions.

[HamsterRN, ADN, RN]

Dictionaries reflect how words are used and the definitions I looked up did not define diagnosis as "a description of a problem".

From my medical dictionary: Diagnosis - " A critical analysis of the nature of something", "The conclusion reached by such analysis"

[ivanh3]

Is there ever a patient with an open wound who *doesn't* have "altered skin integrity"? Of course not. This nursing diagnosis simply puts the assessment into a particular wider category. Pressure ulcer, skin tear, incision - altered skin integrity. The nursing care plan won't depend upon the nursing diagnosis, it will depend upon the specific type of 'alteration' that led to the diagnosis. So what function does 'diagnosis' play in the nursing process there?

Is there ever a patient with an open wound who *doesn't* have "risk for infection"? Of course not. An open wound compromises the body's defense system. No 'critical analysis' there; only one 'conclusion' to reach. Open wound = risk for infection.

I think some of those conclusions are obvious, but I have experience. This is why, for me anyway, I think the only real use for writing or discussing nursing diangoses "NANDA" style is too help nursing students develop their critical thinking skills. I am the first to admit that many of the DXs are similar with similar interventions.

Dictionaries reflect how words are used and the definitions I looked up did not define diagnosis as "a description of a problem".

From my medical dictionary: Diagnosis - " A critical analysis of the nature of something", "The conclusion reached by such analysis"

I would agree with this definition.

[jjjoy, LPN]

Is the diagnosis "risk for infection" a critical analysis of an open wound? Given that all open wounds present a risk for infection, where is the critical analysis there?

A nurse observes a patient gasping and "comes the conclusion" that a patient has an ineffective breathing pattern? No! Gasping IS an ineffective breathing pattern.