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]

How does SOAPIE compare to ADPIE?

Subjective Data - Assessment

Objective Data - Assessment

Assessment - Nursing Diagnosis

Plan - Plan

Implement - Implement

Evaluate - Evaluate

Yes or no?

You beat me to the punch bringing up SOAP notes. I thought about them after logging off allnurses earlier today.

S= Subjective data (Gathering data is the first step in the nursing process

O = Objective data (Gather both types of data)

A = Assessment (Your conclusions about the patient's condition based on your analysis of the data. i.e. Diagnosis)

P = Plan

I = Implement

E = Evaluate

The SOAPIE people (Dartmouth started that if memory serves me correctly.) apparently incorporate "diagnoses" into their conceptualization of "assessment." So, I'm not the only one. Separating them was just something that some nurses decided to do. That doesn't make it a automatically a good idea. It doesn't make it right. That separation was not handed down by God. It was a human decision -- one that can and should be open to review, critique, and revision.

[elkpark]

You're definitely not the only one, llg. I also came up in the days of the APIE acronym (before someone decided that "D" needed to be its own special, separate category), and I also think it's unnecessary to distinguish between "assessment" and "dx." I don't seen any reason why anyone would quibble over whether "diagnosis" is the final step of assessment.

But, then, I don't really understand why we quibble over a lot of the things we quibble over in nursing.

[HamsterRN, ADN, RN]

You're definitely not the only one, llg. I also came up in the days of the APIE acronym (before someone decided that "D" needed to be its own special, separate category), and I also think it's unnecessary to distinguish between "assessment" and "dx." I don't seen any reason why anyone would quibble over whether "diagnosis" is the final step of assessment.

But, then, I don't really understand why we quibble over a lot of the things we quibble over in nursing.

The difference between the APIE and ADPIE is the difference between LPN and RN nursing care. The "D" is what we base our plan of care on.

[jjjoy, LPN]

The difference between the APIE and ADPIE is the difference between LPN and RN nursing care. The "D" is what we base our plan of care on.

It sounds like maybe you are parroting something your nursing school instructors said. Have you seen this for yourself? Do you have any examples of how the different approaches to care between LPNs and RNs?

My instructors said things like this about LPNs and I was later in shock to discover how much responsibility LPNs have in many settings! How could they have so much responsibility when they don't have to think critically or understand the rationales behind their care like RNs do?! But that's getting off topic, isn't it? I do that a lot.

To get back on topic, how about some examples of the difference in nursing care between using APIE and ADPIE?

[Fiona59]

Let's not toss the "LPNs can't critically think" mantra into the fire.

For what it's worth, I know of one LPN who spotted and correctly diagnosed a case of HPV that the ICU staff had missed. But when alerting the doctors it was described as "fleshy, flowering, cauliflower liked growths in genital/perianal area" because nurses aren't permitted to make a medical diagnosis. And yes, the ICU staff missed it.

[llg, PhD, RN]

The difference between the APIE and ADPIE is the difference between LPN and RN nursing care. The "D" is what we base our plan of care on.

I think you are missing the point. We are not saying the LPN's diagnose -- at least I'm not saying that. I am saying that diagnosis is incorporated into the process of assessment. A true assessment of a situation or patient includes 2 steps -- the gathering of information and the drawing of conclusions (diagnoses) based on that information. So, I think that having a separate step in the nursing process called "diagnosis" is redundant because it is already incorporated within the process of assessment.

State boards, etc. seem to recognize that "assessent" includes the "diagnosis" process when they distinguish between LPN data gathering and the necessity of having an RN to complete the assesment process.

I was educated at a time when people were debating whether or not it should be APIE or ADPIE. It was open for discussion and when the NANDA group was formed, things started heading in their direction. That doesn't mean there are no problems with the system.

[HamsterRN, ADN, RN]

LPN's are certainly capable of critical thinking, my point is that RN's need to be capable of it as well. The difference in definition between LPN's and RN's is the degree to which we are expected to apply and act on our critical thinking.

LPN's are expected to assess and then pass that information on to someone else. RN's are expected to assess and evaluate our assessment to formulate our diagnosis which will then direct our care as well as help us determine what we will delegate to others, both "above" us and "below" us.

Examples of the difference between "APIE" and "ADPIE": I'll use the example again of a patient who is admitted for a CHF exacerbation. If you skip the "D" portion, your assessment will find that the patient has wet lungs and BLE edema, and your problem will be "fluid overload". You plan of care will be generic: Diurese, protect their weeping BLE skin, etc.

The Diagnosis portion attempts to cull out the root cause, in this case it may be that the patient stopped taking their lasix because they couldn't afford it, or because they are convinced they are "allergic" to it because it gives them leg cramps, when really their potassium is 3.1. In this case the diagnosis portion would add the need for a social work consult as well as focused diuretic education. Without the diagnosis portion, that patient will be back within the month, with it, you now have a pt specific plan of care that addresses the overall problems.

[jjjoy, LPN]

Determining the reason a patient didn't take their medication was because they are unable to afford their medication and/or need more education is part of a thorough assessment. If a physician or an LPN doesn't dig that deep into the cause of the problem it's because they weren't doing a thorough assessment.

[HamsterRN, ADN, RN]

"Determining the reason", as you put it, is diagnosing. Diagnoses are based on assessment info, but they are not one in the same. If you've been doing that all along then you've been diagnosing all along.

[jjjoy, LPN]

Okay, I'll bite. Sometimes, a diagnosis is as simple as restating the assessment findings as opposed to having to analyze those findings or apply deductive logic.

Assessment: Broken bone sticking out of skin - Diagnosis: compound fracture

Assessment: Heart stops beating - Diagnosis: cardiac arrest

In such cases, assessment = diagnosis. If a broken bone is sticking out of one's skin, you don't need an expert to diagnose it... but you do need an expert to help fix it. If one's heart has stopped beating, it doesn't matter if the clinician never thinks "cardiac arrest" as long as they as they know how to recognize and respond to a heart not beating. The diagnostic process would be more important in cases of vague symptomatology... the patient is fatigued, bruises easily and their urine glows in the dark. Diagnostic work is needed to come up with a plan of action for that problem.

Nursing diagnoses seem to mostly seem like the above examples, assessment = diagnosis. The patient probably doesn't need a nurse to 'diagnose' diarrhea, but they may need the nurse's expertise in managing it. It doesn't matter if a nurse thinks of the diagnosis "impaired mobility" as long as they are adequately addressing the fact that the patient has a broken leg. That doesn't make nursing diagnoses useless. It just means that going from assessment to diagnosis is a translational process. The critical thinking takes place during the assessment process.

[ivanh3]

I am saying that diagnosis is incorporated into the process of assessment. A true assessment of a situation or patient includes 2 steps -- the gathering of information and the drawing of conclusions (diagnoses) based on that information. So, I think that having a separate step in the nursing process called "diagnosis" is redundant because it is already incorporated within the process of assessment.

With all due respect that is not correct. They are absolutely positively two separate and distinct processes. It does not matter what you call them. Under ADPIE, the A is for Assess, not Assessment. Assessment is synonymous with diagnosis (paramedics refer to it as "chief impression"). There is no difference in meaning. "Assess" is only a gathering of data, and it is its own thing. There are entire classes devoted to this subject. People can be really strong at assessment, but perhaps not so strong at drawing the conclusions (or vice versa).

Okay, I'll bite. Sometimes, a diagnosis is as simple as restating the assessment findings as opposed to having to analyze those findings or apply deductive logic.

Assessment: Broken bone sticking out of skin - Diagnosis: compound fracture

Assessment: Heart stops beating - Diagnosis: cardiac arrest

In such cases, assessment = diagnosis. If a broken bone is sticking out of one's skin, you don't need an expert to diagnose it... but you do need an expert to help fix it. If one's heart has stopped beating, it doesn't matter if the clinician never thinks "cardiac arrest" as long as they as they know how to recognize and respond to a heart not beating. The diagnostic process would be more important in cases of vague symptomatology... the patient is fatigued, bruises easily and their urine glows in the dark. Diagnostic work is needed to come up with a plan of action for that problem.

These are medical diagnoses your are using as examples. In the first example, it might not take an expert to recognize that the protruding bone is a fracture, but somebody had to know enough to diagnose it as a compound fracture. What if the bone was not protruding? What if there was only the history of a one story fall off of a roof, inability to bear weight, swelling and tenderness without deformity, good distal pulses and cap refill, x-ray pending. Yes, sometimes the DX is simple and obvious, but sometimes it is not.

Nursing diagnoses seem to mostly seem like the above examples, assessment = diagnosis. The patient probably doesn't need a nurse to 'diagnose' diarrhea, but they may need the nurse's expertise in managing it. It doesn't matter if a nurse thinks of the diagnosis "impaired mobility" as long as they are adequately addressing the fact that the patient has a broken leg. That doesn't make nursing diagnoses useless. It just means that going from assessment to diagnosis is a translational process. The critical thinking takes place during the assessment process.

I can meet you part way on this one. I agreed that many of the Nursing DXs are the "signs and symptoms" for the medical DXs. However, I think that the critical thinking takes place across all stages of the process, not just one or a few. I would say it does matter that " impaired mobility" cross your mind because that might lead you to "risk for fall/injury". I don't care if it is a written care plan or not, but it needs to be in there somewhere.

[llg, PhD, RN]

. Under ADPIE, the A is for Assess, not Assessment. .

Under APIE, A=Assessment. That's the whole point.

ADPIE was not handed down from God. It was a human decision -- one that not everyone agrees with.

And who says that the verb "assess" only includes data gathering and not the making of a judgment? I just looked up the word "assess" in my computer's dictionary it's definition includes the making of a judgment -- not just the gathering of data.

I agree that nurses can and should make nursing diagnoses. I just also happen to agree that the use of the term "diagnosis" combined with the awkward wording of NANDA has caused so much distress and confusion that maybe we would have been better off as a profession had we done things a little differently.

We have all invested so much time, effort, money, blood, sweat, and tears in the NANDA schem -- and seem to have gotten very little benefit from it. I can't help wondering had we chosen another path ... another priority to invest in.

Do nurses in your practice setting really use NANDA language in every-day communications? In my experience, the NANDA language is abandoned when practicing nurses start talking about real patients in real situations. If most practicing nurses don't find it a helpful "language," that should cause us to question it.