Nursing Diagnosis? - page 2

by Critical Care-Bear 6,586 Views | 27 Comments

Hello, I got into an argument with my physical assessment lab instructor and I want some feedback. Okay, we did the "ear, nose, throat" lab last week and my partners tonsils were swollen, she said her throat was sore and... Read More


  1. 0
    Quote from Critical Care-Bear
    Hello,

    I got into an argument with my physical assessment lab instructor and I want some feedback. Okay, we did the "ear, nose, throat" lab last week and my partners tonsils were swollen, she said her throat was sore and complained she wasn't feeling good. So in the write up we have to fill-out these sheets and on the back is a SOAP format, which means we have to list the subjective, objective, assessment, and I think the "P" is for plan of care or something, this is were we give the "diagnosis." So in the last part, I said I would collect throat cultures and send them to the lab to be examined to determine if the infection is bacterial or viral. Then I said that once I get the results I would suggest an antibiotic, such as azithromycin, if the infection is bacterial. If the infection was viral, I would recommend an anti-inflammatory agent or pain killer, such as aspirin, and remind the patient to drink plenty of fluids and get bedrest.

    Anyway, next lab when I walk into class the instructor was going off about how we, as nurses, don't order medications. I knew she was talking about my paper. So before I sat down I said "well can't we suggest a course of therapy
    or medication to the doctor?" She then said that we couldn't because the patient could be allergic to a particular medicine. I then told her that one of the first pieces of information we collect in an assessment is the patient's allergies. The teacher then kinda yelled at me and said, quite frankly, "YOU'RE
    NOT A DOCTOR."

    This is rediculous, Med-students only take 1 pharmacology course too. I've talked to med-students and they say that alot of the knowledge involved in prescribing a certain medication has to be learned on their own. Some nurses have 20 or more years of experience, I'm sure they can offer insight by suggesting medications to a Doctor. Am I wrong?

    The teacher told me that what she was looking for was "nursing diagnosis's."
    She suggested things like "adjusting the patients pillows." I'm not paying $500 a credit to learn how to fluff pillows! I want to be an active member in the healthcare process, not some ******* orderly. Does anybody feel me, or am I just going nuts? I think I'll get a prescription for xanax. This really gives me aggita. :angryfire
    We've been doing SOAP notes and the Assessment is where you put your nursing diagnosis (Ex "Pain r/t red, inflamed tonsils") Then your P is your Plan, otherwise known as your therapeutic nursing interventions(Ex. Throat culture as ordered, warm gargle, prn pain meds as ordered)
    You NEVER write a medical diagnosis in your note. You might say to the doc, yeah she looks like she might have strep, if the doc asks your opinion, but you NEVER medically diagnose. You can lose your license for that.
    As far as fluffuing pillows, that is a nursing intervention, which you would do in response to your nursing diagnosis. You are helping the patient become more comfortable. You are not paying money to learn how to fluff pillows, and your instructor could have said it better, but you are learning how to help your patients and use your knowledge of nursing process to help the patient cope with illness etc.
    I think like a nurse practitioner too, since I've worked with them for so long, and I tend to think about or try to guess what the medical diagnosis would be, but as a nurse you NEVER write it down and you never tell the patient a medical diagnosis without the doctor determining it first.
  2. 0
    All right, here's some feedback for you. SOAP - each letter stands for Subjective symptoms (what the patient tells you), Objective observations (what you actually see, hear, feel, smell during your assessment), Assessment (after considering the subjective and objective information, what you feel, as a nurse, is going on--you cannot use any medical diagnosis terms), and Plan (plan of action. . .what you, the nurse are going to do about this situation).

    In your scenario your statement in the assessment section could very simply be "reddened, sore throat". In your scenario some of the things you could list in your plan of action would be (1) advise patient to contact her MD (2) gargle with warm saline (3) drink warm tea with lemon to sooth throat (4) notify (that means you the nurse) the doctor of the patients signs and symptoms. There are other nursing measures that could be taken as well. I just listed the ones that came to mind. Where you went wrong is that you jumped the gun on the treatments. You can't send a throat culture to the lab or give any medications until they are ordered by the doctor. That happens when you notify the doctor of the signs and symptoms the patient is having. Once you have those orders, the appropriate comment to put in the plan of action is "obtain throat culture as ordered" and "give antibiotics as ordered".

    When you are writing SOAP notes, or any nursing notes, your charting must always reflect you, the nurse's, point of view and nursing actions. Notifying the doctor and carrying out doctor's orders are nursing tasks and it is quite appropriate to include these in a plan of nursing and to make notation that indicates you are following the doctor's orders. Remember that there are some things nurses can do independently, but there are a great many others that only a doctor may order. You need to understand the distinction between these two ideas. Don't fret over this. This is why you are learning. No one likes learning "the hard way", but I'm willing to bet that you'll be less likely to make this same kind of mistake again.
  3. 0
    Quote from Critical Care-Bear
    Hello,
    Okay, we did the "ear, nose, throat" lab last week and my partners tonsils were swollen, she said her throat was sore and complained she wasn't feeling good. So in the write up we have to fill-out these sheets and on the back is a SOAP format, which means we have to list the subjective, objective, assessment, and I think the "P" is for plan of care or something, this is were we give the "diagnosis." So in the last part, I said I would collect throat cultures and send them to the lab to be examined to determine if the infection is bacterial or viral. Then I said that once I get the results I would suggest an antibiotic, such as azithromycin, if the infection is bacterial. If the infection was viral, I would recommend an anti-inflammatory agent or pain killer, such as aspirin, and remind the patient to drink plenty of fluids and get bedrest.
    I'm not a nurse (or nursing student) so I'll defer that part of your post to others with more experience with this matter. (then why am I posting? - I think this is a great teaching case - oh, the rest of this post will be in the style of socratic teaching, i.e., mostly questions but think of them as prompts to get you thinking and go "hmmmm")

    So you have a patient in front of you complaining of sore throat, "not feeling good", and has swollen tonsils. What do you think is the most likely diagnosis? What else would be in your differential?

    (setting aside the proper roles of nurses/doctors) - so you would swab the throat and send to the lab for culture. How long will it take for the labs to send you results? What do you do with the patient in the meanwhile? What are the consequences if you delay treatment? What other in-office test can you do? What is the sensitivity and specificity of this test? What other physical findings will help in the diagnosis?

    Lastly, under what circumstances do you think will warrant hospitalization/admission? Under what circumstances is taking a throat swab a bad idea?
  4. 0
    Quote from JessLpn14
    I think you are going nuts. Go to med school if you want to prescribe meds, or be a Nurse practitioner.
    I am confused by your response here. This is a forum where students come to ask questions and be supported in their schooling process. There is no cause for such inflammatory remarks here. This student is asking a valid question!!! It's very true that in the real world nurses suggest things to doctors - it is not always well taken, but it happens, often with the best outcome for the patient. This student is not saying that she is wanting to prescribe meds - she's just asking where she went wrong and asking how to do it better! Obviously, she knows that nurses do not prescribe meds - she is going on what she knows will most likely be ordered to be done. Just because she got a little off track in that on this one assignment does not mean she needs to be attacked.
  5. 0
    Can a nurse perform a throat culture as an independent nursing action, or does it need to be ordered?
    It seems grey to me.
  6. 0
    Quote from Coopergrrl
    Can a nurse perform a throat culture as an independent nursing action, or does it need to be ordered?
    It seems grey to me.
    Any place I have ever worked it must be ordered by Dr. Don't know for sure if that applies to everyone, this is just my experience.
  7. 0
    Thanks student4ever. Haha I wasn't too offended though about the remark. My school is actually gonna let me start the nurse practitioner program before I finish my BSN because I already have a BS in Bio. I just don't understand why or how it's a whole different ballgame being a nurse practitioner? I mean it's a "nurse" practitioner not a "medical" practitioner or general practitioner or family, etc. Yet, as an NP, all of a sudden you're suppose to think medically. You have to know how to diagnose and what to prescribe, what tests to do, etc. However, as a nursing student, who's going to be an NP, I get repremanded for trying to think like an NP. That doesn't make sense to me. So basically they want you to learn all this in a 2 year master program. The physical assessment book has abnormalities at the end of each chapter, I think they could have included a section on treatments.

    Anyway, thanks for all your responses. Coopergrrl, you have the same name as me, my last name is cooper. I'm not a "she" though. . .
  8. 0
    Quote from Critical Care-Bear
    However, as a nursing student, who's going to be an NP, I get repremanded for trying to think like an NP. That doesn't make sense to me. So basically they want you to learn all this in a 2 year master program. The physical assessment book has abnormalities at the end of each chapter, I think they could have included a section on treatments.

    You answered your own question. You are a nursing student. Now is the time to think like a nurse. When you're in the NP level courses, then you think like a nurse practioner. Crazy huh?

    Play their game Mr. Cooper, play their game. Life will be easier. Not that you can't be an independent critical thinker, because it's obvious you are. Just in your interactions with your instructors and on paper, think and act like a student nurse. Whether or not it makes sense to you.
    Last edit by Tweety on Nov 7, '05
  9. 0
    Quote from Critical Care-Bear
    Thanks student4ever. Haha I wasn't too offended though about the remark. My school is actually gonna let me start the nurse practitioner program before I finish my BSN because I already have a BS in Bio. I just don't understand why or how it's a whole different ballgame being a nurse practitioner? I mean it's a "nurse" practitioner not a "medical" practitioner or general practitioner or family, etc. Yet, as an NP, all of a sudden you're suppose to think medically. You have to know how to diagnose and what to prescribe, what tests to do, etc. However, as a nursing student, who's going to be an NP, I get repremanded for trying to think like an NP. That doesn't make sense to me. So basically they want you to learn all this in a 2 year master program. The physical assessment book has abnormalities at the end of each chapter, I think they could have included a section on treatments.

    Anyway, thanks for all your responses. Coopergrrl, you have the same name as me, my last name is cooper. I'm not a "she" though. . .
    I appologize for assuming you are a "she." Congrats on going into the NP field! THat is my ultimate goal, eventually one day! As said above, the trick is to play by the rules. You will learn a lot from your nursing classes (and if you work as an RN before becoming an NP) that will help you to know what kinds of tests to order - nurses are on the front line in that department - they pay close attention to patients' symptoms, and communicate them with the doctor or NP. Watching what doctors order for the symptoms will help you develop that sense, along with the NP training you will receive. Good luck to you in all your endeavors!
  10. 0
    Quote from Tweety
    You answered your own question. You are a nursing student. Now is the time to think like a nurse. When you're in the NP level courses, then you think like a nurse practioner. Crazy huh?

    Play their game Mr. Cooper, play their game. Life will be easier. Not that you can't be an independent critical thinker, because it's obvious you are. Just in your interactions with your instructors and on paper, think and act like a student nurse. Whether or not it makes sense to you.
    Well said, Tweety. It isn't only the skills, knowledge, and experience we acquire in school, but also an awareness of the social/professional behaviors expected in the working world. Because this education is interwoven throughout our programs, you won't find courses labeled "How to Keep Your Mouth Shut When You Know You Have Something Worth Saying," or "Communicating Tactfully With Pompous Blowhards." Nevertheless, you will be given ample opportunity to learn the material.


Top