Nursing Diagnosis?

  1. 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
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  2. 27 Comments

  3. by   Tweety
    I know it's aggravating but you have to play their game.

    The instructor is looking for what you as a nurse would do. Not what the MD would do.

    You would report the symptoms to the md "throat swollen, feels bad, etc." You're right, in the real world you can recommend things to the MD.

    I would think if you put the nursing interventions first, then say something like " obtain cultures and administer antibiodics, NSAIDS as ordered" might be more acceptable to your instructor rather than how you put it.
  4. by   CallMePatti
    Nursing Diagnoses are ones that nurses can attend to independently (or collaboratively).

    It also needs to be a NANDA dx.

    I don't know what exactly you wrote as your dx, but remember that as a nurse, you wouldn't even have the authority to order a throat culture on that patient.

    Once a medical dx is determined, a better nursing dx for this patient might be something like:

    Fatigue, related to viral infection as manifested by enlarged lymph nodes and general malaise.

    Hope this helps!
  5. by   skyyhiflygirl
    Think of it this way. When you are taking the NCLEX, the right answer for the test is ALWAYS going to be the independent nursing intervention. Suggesting which course of antibiotics for the doc to prescribe is NEVER going to be the right answer on the NCLEX. The instructors are there to make sure we pass boards and get licensed as nurses.

    At my school we spend a LOT of time talking about independent nursing interventions and how we go about using them. We have to write independent nursing interventions into EVERYTHING we turn in and the rationale behind the intervention. Because this was not the case at a previous school I went to, I went out and got a really good care plan book that marks dependent, independent and collaborative interventions. It saved my life here at this school. And yes, as long as this is the school you go to for your degree, you have to play their game.
  6. by   JessLpn14
    I think you are going nuts. Go to med school if you want to prescribe meds, or be a Nurse practitioner.
  7. by   belabelisa
    Well... nursing diagnoses and medical diagnoses are very different things. Our job isn't to provide medical diagnoses, but we have plenty of nursing diagnoses from which to choose. I certainly don't think that your instructor should have yelled at you, but I do agree with him/her. We aren't physicians. Our role is to look at our patient as a whole person and our diagnoses reflect that. It's much more than fluffing pillows, but it doesn't involve ordering throat cultures and medications. Sure there are situations where you would need to express your opinions about medications and tests. However, this is just normal collaboration and not a nursing diagnosis. Lab instructors want to see what you would actually write when on the job. If you were to start suggesting meds and ordering tests, you would be going way beyond your scope of practice.

    As a side note, I bought a book of nursing diagnoses that has been a great help in my labs.
  8. by   Nurseismade RN
    Hi,

    What Care Plan book did you get?????
  9. by   GrnHonu99
    Sometimes it takes a minute to understand nursing diagnoses...it can be frustrating when you know what should be done but can't do it..we have to stick to our scope of practice...
  10. by   luvmy2angels
    Unfortunaltey your instructor is right. It is NOT our job to make a medical diagnosis or suggest an RX be given. A Nursing diagnosis is something that the nurse can do on her own, without having a Dr order. It does get confusing sometimes but with lots of practice it becomes easier. You should still learn and know about the medications though. Pt often have questions about them that they will ask YOU. I just finished my ER rotation and almost every pt that I discharged had a question about the med they were prescribed! You WILL need the knowledge about pharmacology, you just won't be using it to prescribe!! Best of luck to ya!!
  11. by   skyyhiflygirl
    I purchased the Gulanick "Nursing
    Care Plans" book. It has been a lifesaver.
  12. by   MIA-RN1
    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.
  13. by   Daytonite
    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.
  14. by   group_theory
    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?

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