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

)

[HamsterRN, ADN, RN]

In nursing, Assessing a patient means to gather information, diagnosing is using that information to find root causes and to find solutions. If you base your plan of care on assessment only, then you'll only be treating the effects of the problem, and not trying to solve the root cause, and if that's the case, then what's the point?

[jjjoy, LPN]

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.

I don't know about you but I can go straight from seeing someone with a leg in a fresh cast to 'risk for falls' without going through 'impaired mobility' to get there.

[jjjoy, LPN]

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.

But broken, protuding bone IS the definition of 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.

'Fracture' would be a tentative diagnosis until the x-ray confirmed it. A clinician would review the x-ray and make the diagnosis of fracture based upon their assessment of the x-ray image. X-ray image = fracture. Assessment = diagnosis.

I agreed that many of the Nursing DXs are the "signs and symptoms" for the medical DXs.

Those nursing diagnoses that are signs and symptoms (diarrhea, insomnia, pain, confusion), then ARE assessments, are they not?

[ivanh3]

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.

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.

No, I have only had one job where we used NANDA style care plans, and even in that position they were rarely enforced or done. I mainly see the NANDA/care plan thing as great tool for teaching students how to organize and develop their critical thinking skills.

But broken, protuding bone IS the definition of compound fracture.

'Fracture' would be a tentative diagnosis until the x-ray confirmed it. A clinician would review the x-ray and make the diagnosis of fracture based upon their assessment of the x-ray image. X-ray image = fracture. Assessment = diagnosis.

Those nursing diagnoses that are signs and symptoms (diarrhea, insomnia, pain, confusion), then ARE assessments, are they not?

I am not sure where this is going anymore so back to the OP: Yes, nurses do diagnose. They officially make nursing diagnoses. They may not write 'em down in a care plan, and to some RNs with even the smallest amount of experience they may seem easy/obvious/trivial and completely unnecessary. I keep seeing nurses post how obvious these nursing DXs are. Well I am here to tell you that to some people they are not. For a significant number of students the hand holding through the process is necessary. It does not mean these students are dumb, but that they have not quite developed critical thinking yet. Some of these students have never been exposed to this stuff at all. That is why they are in school. You walk in a room with patient that has been weak and note that his bed rail is down. You walk over and put his bed rail back up. You re-check every time you are in his room until you note that the weakness is resolved and there is no longer a fall risk. You might have run through those steps subconsciously at the speed of lightning fast thought. You might not have even realized you put the rail up. A student however would benefit being able to articulate that process and then build upon it with more complex problems.

Nurses must also work with medical diagnoses. As an advanced practice RN I make medical diagnoses, and as a staff/bedside RN I work with medical diagnoses. If team plan is to work the DKA or asthma pathways, then I must understand those medical diagnoses. We give patient teaching sheets with the medical diagnosis written right across the top of the page. I must be able to go over those instructions with the patients as a bedside/staff RN.

Also, the assessment phase and diagnosis phase are two distinct processes. You can take the word nursing and medical out of it. Just about any problem solving process involves some type of investigating and then some type of drawing a conclusion.

[jjjoy, LPN]

I mainly see the NANDA/care plan thing as great tool for teaching students how to organize and develop their critical thinking skills.

I agree that care plans are a useful learning tool. I personally found NANDA to make things *more* confusing, though, not less. I figured out how to apply nursing diagnoses more or less; after all I did graduate. But if they were *that* useful, I'd think more people would learn them and eventually go "aha! now it all makes sense!" as opposed to "huh, doesn't look like anyone really uses these things."

I keep seeing nurses post how obvious these nursing DXs are. Well I am here to tell you that to some people they are not.

What's wrong with them being obvious? We certainly don't want to graduate nurses who would miss recognizing pretty basic things... unsteady gait (risk for falls, impaired mobility), inability to feed self (self-care deficit, risk for altered nutrition), break in skin defenses (altered skin integrity, risk for infection).

Maybe that's where I get hung up on nursing diagnoses... when people try to make them seem more complicated than they are. It's true that such basics may NOT be obvious to anyone, but they ARE obvious to a lot of people, and SHOULD be obvious to nurses. So to insist that nursing diagnoses are NOT obvious makes nurses look kind of dumb... maybe?

You walk in a room with patient that has been weak and note that his bed rail is down. You walk over and put his bed rail back up. You re-check every time you are in his room until you note that the weakness is resolved and there is no longer a fall risk. You might have run through those steps subconsciously at the speed of lightning fast thought. You might not have even realized you put the rail up. A student however would benefit being able to articulate that process and then build upon it with more complex problems.

I agree that maybe not everyone immediately recognizes that weakness = risk for falls, but I'd hope nursing school admissions would screen out those applicants for whom making that connection is difficult. Now *what to do* about risk for falls (side rails up, putting call bell in reach, how to use assistive devices, etc) THAT is what I expect nursing school to teach.

Hmmm... how about a new argument? Certain conditions are obvious in what nursing diagnoses apply. And that's okay. By the end of first term, students should be able to recognize and diagnose the most obvious presentation of certain conditions... diarrhea, confusion, impaired mobility, risk for falls, self-care deficit, etc. Of course, students ARE taught to recognize these things, but what's wrong with acknowledging that these are ground-floor fundamentals that *should* be obvious to anyone who wants to call themselves a nurse?

[HamsterRN, ADN, RN]

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.

We recently went through a Joint Commission visit and had to go through all of our care plan templates before they came to make sure there was no longer any NANDA terminology used. The Joint Commission's current focus is on improving interdisciplinary communication, a goal that NANDA nursing diagnoses certainly don't help with.

Nursing schools seem to be the last strongholds of NANDA terminology, although Patricia Benner pretty well did away with the idea that NANDA was of any use in nursing education in her latest book, it will probably still be years before nursing schools 'see the light'.

[anonymurse]

When I call a doc, I'd better have either (a) a diagnosis for him (however worded, and complete with evidence for the dx) plus the solution I want, or (b) a request he come look at the pt now because I don't have a clue how to come up with (a).

[netglow, ASN, RN]

We recently went through a Joint Commission visit and had to go through all of our care plan templates before they came to make sure there was no longer any NANDA terminology used. The Joint Commission's current focus is on improving interdisciplinary communication, a goal that NANDA nursing diagnoses certainly don't help with.

Nursing schools seem to be the last strongholds of NANDA terminology, although Patricia Benner pretty well did away with the idea that NANDA was of any use in nursing education in her latest book, it will probably still be years before nursing schools 'see the light'.

Thank God for this! Sheesh.

Sick is sick, lets just get down to it and treat the patient. And yes we ARE part of the team that practices medicine!!! (I am aware that this is a shock to some who never knew this). Lets get rid of the whole NANDA deal and just use clinical pathways that are known to all.

[jjjoy, LPN]

When I call a doc, I'd better have either (a) a diagnosis for him (however worded, and complete with evidence for the dx) plus the solution I want, or (b) a request he come look at the pt now because I don't have a clue how to come up with (a).

I took that under consideration for my original argument in this thread. That argument is that what RNs offer is professional assessment and management of health conditions, whereas MDs (and NPs) offer professional diagnosis and treatment of health conditions. Hangnails generally don't require professional diagnosis and treatment but cancers do.

Diarrhea generally doesn't require professional assessment and management but in a certain circumstances it does. Nurses provide that professional assessment and management if needed. They don't "diagnose" diarrhea; they assess the patient and determine the severity of the problem and how to handle it. To do that well, the nurse needs to be able to be aware of and recognize (which involves engaging in the diagnostic process) the vast spectrum of possible medical conditions that affect diarrhea.

If an RN 'suspects' an as yet undiagnosed medical condition, the RN refers the patient to an MD (or NP, etc) who confers the formal diagnosis and leads the medical treatment plan. It's true that any one particular RN might very well be a better diagnostician than any one particular MD, but the general professional training of an MD involves medical diagnosis, while general RN training does not. Still, nurse can *and should* assess symptoms A, B, C 'look like' medical condition X. They need that knowledge to make sound clinical judgements and communicate effectively.

On the other hand, RNs have more professional training in the management of health conditions (preventing skin breakdown, navigating ADLs with limitations, encouraing patient compliance, etc.) If an MD suspects that a patient could use help managing their health condition, they could refer the patient to an RN. The RN will do a professional nursing assessment and build & implement a professional plan of care to manage the situation (maintaining hydration, assuring maximum mobility, etc). However, if the nurse assesses a critical, acute medical condition evolving such as shock, cardiac arrest, etc, then the nurse institutes appropriate emergency medical treatment without waiting for a formal, MD-approved medical diagnosis.

There is definitely overlap between professional nursing and professional medicine in the above definitions. In certain situations, either RN or MD would be sufficient to deal with a health problem. Many times, both have something to offer. To diagnose cancer and plan and implement medical treatment, it's a good idea to consult with an MD. While undergoing treatment, it's a good idea to have an RN monitor (assess) the patient and manage side effects. If there's not a viable medical treatment, you probably want a professional nurse to provide hospice care.