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

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    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.
    ---------------
    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
    )
    ivanh3 and forthebirds like this.
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  3. 44 Comments so far...

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    If I'm understanding you correctly, I agree. I'm not sure where the rumor got started that Nurses aren't allowed to diagnose, we're actually expected to diagnose of you read most states' standards of practice and the ANA standards, this includes diagnosing medical conditions.
    When we have a patient who recently had an MI, and they start to have difficulty breathing and their lungs start to sound wet, we're expected to recognize the beginnings of flash pulmonary edema due to decompensated heart failure, that's how we know how to focus our assessment and what to ask the doc for, or even to act independently of the Doc using ACLS .

    It's unfortunate that the term "Nursing Diagnosis" has gotten such a bad ring to it that we have to invent pseudonyms for the name, hopefully someday we'll be able to re-define the term.

    The only limit to a nurses ability to diagnose, is that medicare and insurer billing based on a diagnosis usually needs to come from a licensed independent practitioner. Other than that, diagnose to your heart's content.
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    I think many times people do not understand that we are not the Doctor's assistants and we do not practice medicine.

    MDs treat disease, Nurses treat people. Hence the difference in the diagnosis. MD diagnosis are disease centered, Nursing diagnosis are patient centered.

    Doc says you have xxx disease, Nurse says you are reacting to the disease in xxx way.

    I do not like the term "Professional nursing assessments" because it mixes what an assessment is and what a Nursing diagnosis is.

    A Nursing diagnosis is the end conclusion of the Nursing assessment. You would be squishing the A and D together in ADPIE.
    sigel55 likes this.
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    In my mind I always diagnose,only in my mind though.I always label 80-90 something patients with a slight dementia and a heart failure regardless of MD diagnosis
    SunnyAndrsn likes this.
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    I do think the terminology "nursing diagnoses" confuses matters, plus tends to make nurses look, well, kinda dumb. Establishing that a patient has diarrhea, pain, impaired mobility, decreased cardiac output, increased risk for falls is an important step in identifying nursing needs and developing a plan of care. It takes clinical assessment skills and knowledge to thoroughly evaluate nursing needs. But it doesn't take the diagnostic process.

    On the other hand, nurses DO use the diagnostic process when evaluating nursing needs, just not to determine 'nursing diagnoses'... eg a patient's foot turns cold after a peripheral vascular intervention. The nurse will use the diagnostic process to conclude that the patient may be experiencing acute arterial thrombosis. The nurse may not officially make that diagnosis, but their nursing assessment and plans will be instructed by their knowledge of the condition. On the other hand, for the nurse to conclude "altered tissue perfusion" does not require the diagnostic process. It's a description of the condition.

    Food for thought...

    "In the case of nursing, four major components were originally described: assessment, planning, implementation, evaluation. ...nurses at some point are expected to identify a person's actual and/or potential needs for nursing... This has increasingly been identified as a phase of the nursing process in its own right, referred to as the nursing diagnosis."
    Wiley InterScience :: Session Cookies

    "The effort to create a meaningful distinction between "observing" and "diagnosing" is impossible. No physician realistically expects a nurse to report everything observed as if the nurse were a video camera. What the physician expects is for the nurse to observe and report only the patterns and isolated facts which would lead the physician to a diagnosis. An understanding of human nature would suggest that the ability to observe the facts which would lead to a diagnosis of a disease requires the equivalent of the ability to diagnose the disease."
    AANA - Legal Briefs -- 12/93 -- Baptists Medical Center Montclair v. Wilson
    kaliRN likes this.
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    Quote from Asystole RN
    A Nursing diagnosis is the end conclusion of the Nursing assessment. You would be squishing the A and D together in ADPIE.
    Exactly. I don't think "D" is a necessary part of the nursing process.
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    Quote from jjjoy
    #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.
    Completely and totally disagree with this. I do not diagnose, am not responsible for diagnostics, and do not want to be held liable or responsible for diagnosing disease. This is not within the scope of practice of an RN. I practice in critical care, which stretches my skills, knowledge, and ability within my license to it's max capacity. I know full well I am not qualified to make a medical diagnosis.

    Nearly all medical problems have cluster symptoms. As nurses, we are educated to know what these symptoms are and to help manage the course of illness, but that doesn't mean we can necessarily differentiate subtle differences in patient condition that would change the differential. We aren't trained to that degree, period, no matter how rigorous or prestigious your nursing program was. Sometimes we can beat the official written diagnosis to the chart in our heads, and sometimes we can't. Either way, it doesn't really matter, because we can't formulate a medical plan of care, so in my mind, it's a mute point.

    Physicians and mid-level providers go to school a minimum of two years beyond a Bachelor's degree (obviously much more for physician specialties) to be specifically trained in pathophysiology, diagnostics, and physical assessment. If you think for two minutes you have that level of education and licensure to back you up, you are sorely mistaken. Sorry, I'll stick with the hated NANDA "constipation" as opposed to SBO, and "impaired gas exchange", as opposed to "klebsiella pneumonia."

    Doesn't mean nurses are stupid, or they should be disrespected. Just sayin.
    kaliRN, elkpark, and leslie :-D like this.
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    #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.
    I included the bolded sentence so as not to exclude what nurse practitioners do from the definition of 'professional nursing care'.
    kaliRN likes this.
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    Quote from jjjoy
    Exactly. I don't think "D" is a necessary part of the nursing process.
    I agree. I was not taught ADPIE as an undergraduate. We were taught APIE as the correct definition of the nursing process. Actually, "assessment" means to both gather data and to draw conclusions from that data (i.e. "diagnose.") Therefore, the "D" is conceptually redundant.

    When I have taught assessment, I have always emphasized that it is not just data gathering. A lot of people (e.g. nursing assistants) can gather data. However, it is the professional nurse who can organize, analyze, and draw conclusions from that data. That's why nurse practice acts, nursing standards, etc. say that only RN's can officially assess the patients -- and that LPN's, CNA's, etc. need that RN involvement to finalize admission assessment, plans of care, etc.

    I also agree that using the word "diagnosis," while technically correct has gotten us into more trouble than its worth as most people don't take the trouble to really sort out and understand the distinctions between the roles well enough to be comfortable with the use of the same word to refer to many different types of diagnoses. I just hate to think that nurses should abandon this correct term only because "the physicians got there first" and cornered the market on the use of this word.
    Last edit by llg on Jul 21, '10
    elkpark and nursemike like this.
  12. 0
    Quote from llg
    I agree. I was not taught ADPIE as an undergraduate. We were taught APIE as the correct definition of the nursing process. Actually, "assessment" means to both gather data and to draw conclusions from that data (i.e. "diagnose.") Therefore, the "D" is conceptually redundant.
    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.

    Quote from llg
    When I have taught assessment, I have always emphasized that it is not just data gathering. A lot of people (e.g. nursing assistants) can gather data. However, it is the professional nurse who can organize, analyze, and draw conclusions from that data. That's why nurse practice acts, nursing standards, etc. say that only RN's can officially assess the patients -- and that LPN's, CNA's, etc. need that RN involvement to finalize admission assessment, plans of care, etc.

    I also agree that using the word "diagnosis," while technically correct has gotten us into more trouble than its worth as most people don't take the trouble to really sort out and understand the distinctions between the roles well enough to be comfortable with the use of the same word to refer to many different types of diagnoses. I just hate to think that nurses should abandon this correct term only because "the physicians got their first" and cornered the market on the use of this word.
    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


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