The Usefullness of Nursing Diagnosis in Medical Decision Making - page 2

I think you guys are focusing on the time commitment of MD vs DNP too much. Even if the MD route is long by just a few years, you're not factoring in how difficult the path is. If you know someone... Read More

  1. by   SuesquatchRN
    Quote from core0
    On the subject of using the nurses assessment, the first thing I was taught is never use any one elses assessment ever. If you are going to make a mistake, make it yourself, don't perpetuate someone elses. I will look at other assessments to see when a change occurred.
    David, this is some of the most concise, valuable advice I've seen.

    I just want you to know that when I see your name in a thread I end up reading it. You're a font of knowledge, and thank you for sharing it.
  2. by   core0
    Quote from jzzy88
    nursing diagnosis and the use of were not what i was concerned about. i don't know if nurses actually use those in practice and i don't care if they do. my concern was that you seemed to be saying that a nurses actual assessment, like "somethings not right here or something is not wrong here" are ignored by docs.
    nursing assessment is valuable. the entire forests of trees killed documenting it are not. there are two different statements you made.
    one is the nature of how a diagnosis is arrived at.
    "but don't nurses do the initial assessment. that's what i've been taught so far. and i've also been taught that nursing diagnoses aren't used. what i've learned about nursing is that nurses are the first ones to assess the pt's condition and the doc/pa/np comes in and finds out what the nurse observed, then does their own assessment, tests and diagnosis."

    outside of the er it really doesn't happen that way. a nursing assessment (at least the ones that i have seen) takes a while. that is a while i don't have. i can do a good history and exam in about 20 minutes on a moderately complex patient. the history will make my diagnosis more than 80% of the time. the pe will make it another 5%. the remaining 15% of the time i form a working diagnosis, a likely list of suspects and initiate a treatment plan to treat the underlying condition while using tests to rule out or in other diagnosis. this is how medical decision making works. i really don't need anyone elses assessment to do this.

    now the second part is spot on. i absolutely rely on nurses to say that something is not right here or that something is wrong. also even if they can't pinpoint why the statement that someone is getting worse is always listened to. nurse have the advantage of spending large amounts of time with the patient. nurses also have the disadvantage of spending large amounts of time with the patient. sometimes the advantage lies in stepping back and being able to see a broader picture.

    the other place that i use the nurses assessment is the overall gestalt of the patient. sometimes the patients symptoms and complaints don't really mesh. then having another pair of eyes for example "what do you think of her pain" is helpful. or if i am having trouble hearing bowel sounds over the ventilator (thank the army for my high frequency hearing loss) then asking the nurse if she hears any confirms what i am hearing.

    i'm certain that we use our own assessments, but don't we collaborate to come to a conclusion together. or do docs and the like say in essence "here, you moron, go do the teaching." that's what concerned me was the demeaning tone.
    i don't mean to be demeaning, i'm just explaining the way it is. i have had student nurses present me with their nursing assessments but i still don't use them (i do usually correct them since i am getting pretty good at the taxonomy). but the diagnosis has to be mine. i am ultimately responsible for it. i use all the available information including nursing input but collaboration is a little strong a word.

    i recognize and respect your expertise in your field, but when you make sweeping generalizations, i feel compelled to question you. i also feel compelled, as someone with a b.a. degree molec. and cell biology, with a love of biochemistry, that it ain't the whole story. and we can never say that just b/c something happens to bind to a receptor that that binding will have the same effect all of the time. mutations and changes can happen in the cell. genes can change the receptors, etc. the body is infinitely complex, and i doubt we will ever understand it's mystery and docs and others who know it all, should be a little more humble in their practice.

    as someone with a degree in molecular genetics and political science i understand the dual nature of the universe. however even chaos theory says that statistically something will happen. to count on a site mutation on every patient is not statistically likely. nobody knows everything about medicine. it is however, in theory, a practice based on science. the paradigm of evidenced based medicine is the use of current best evidence in making decisions about an individual patient. this is seen in nursing (dvt prophylaxis and decub strategies) and in medicine. we can't claim that we know it all. we do know a lot and there is a lot we can and should do (and shouldn't).


    will getting a doctorate finally get people to stop assuming and treating nursing and nurses like morons? will it validate nursing as a worthy pursuit?
    j
    the dnp will not automatically give nursing validation. if anything nps should be competency based and that should give them validation.

    what you are really looking for is assurance that nursing is a worthy pursuit and it is. if you are looking for assurance that learning nursing diagnosis will validate nursing then i am afraid you are in for a disappointment. nursing assessment if done in a thoughtful manner is a help. nursing assessment in the current form is a hindrance and does nothing to validate nursing as a worthy pursuit.

    david carpenter, pa-c
  3. by   core0
    Quote from Suesquatch
    David, this is some of the most concise, valuable advice I've seen.

    I just want you to know that when I see your name in a thread I end up reading it. You're a font of knowledge, and thank you for sharing it.
    We talk about lifetime learning and that is true but incumbent on that is also lifetime teaching.

    David Carpenter, PA-C
  4. by   silas2642
    Quote from jzzy88
    Nursing diagnosis and the use of were not what I was concerned about. I don't know if nurses actually use those in practice and I don't care if they do. My concern was that you seemed to be saying that a nurses actual assessment, like "somethings not right here or something is not wrong here" are ignored by docs. I'm certain that we use our own assessments, but don't we collaborate to come to a conclusion together. Or do docs and the like say in essence "here, you moron, go do the teaching." That's what concerned me was the demeaning tone. I recognize and respect your expertise in your field, but when you make sweeping generalizations, I feel compelled to question you. I also feel compelled, as someone with a b.a. degree molec. and cell biology, with a love of biochemistry, that it ain't the whole story. And we can never say that just b/c something happens to bind to a receptor that that binding will have the same effect all of the time. Mutations and changes can happen in the cell. Genes can change the receptors, etc. The body is infinitely complex, and I doubt we will ever understand it's mystery and docs and others who know it all, should be a little more humble in their practice.



    Will getting a doctorate finally get people to stop assuming and treating nursing and nurses like morons? Will it validate nursing as a worthy pursuit?
    J
    I don't think that coreo is saying that nurses' observations should be ignored- he's not saying that at all. What he is saying is that when the status of a patient has changed, he wants to see the patient himself, because he and the physician is ultimately responsible for the care of the patient, not the nurse.

    As far as the initial assessment of the pt. by the nurse, it is hard to blame the doctors for not reading the nursing assessments. They're going to have to complete a hx. and physical examination themselves anyway, and they are very busy, so I'm sure that a lot of times they just don't have time to read the nursing notes.

    Anyone who has worked in a hospital knows how crucial a role the nurses play-- they are the eyes and ears of the physicians. However, the physicians are still the minds, and since they are the ones who are ultimately responsible for the patient, they want to be there to assess the patient and make sure that the decisions are made properly.
  5. by   amzyRN
    Quote from silas2642
    I don't think that coreo is saying that nurses' observations should be ignored- he's not saying that at all. What he is saying is that when the status of a patient has changed, he wants to see the patient himself, because he and the physician is ultimately responsible for the care of the patient, not the nurse.

    As far as the initial assessment of the pt. by the nurse, it is hard to blame the doctors for not reading the nursing assessments. They're going to have to complete a hx. and physical examination themselves anyway, and they are very busy, so I'm sure that a lot of times they just don't have time to read the nursing notes.

    Anyone who has worked in a hospital knows how crucial a role the nurses play-- they are the eyes and ears of the physicians. However, the physicians are still the minds, and since they are the ones who are ultimately responsible for the patient, they want to be there to assess the patient and make sure that the decisions are made properly.
    So, you say that nurses are only the eyes and ears of the physician and not the minds? Is this true?

    I'm surprised I haven't heard anyone say any different, perhaps it is true that nurses are just the handmaiden of the physician. What a big disappointment! And I suppose that the DNP is a waste of time!
    J
  6. by   SuesquatchRN
    Quote from silas2642
    Anyone who has worked in a hospital knows how crucial a role the nurses play-- they are the eyes and ears of the physicians. However, the physicians are still the minds, and since they are the ones who are ultimately responsible for the patient, they want to be there to assess the patient and make sure that the decisions are made properly.
    I beg your pardon?
  7. by   amzyRN
    Just wanted to say that I very much appreciate everyone's input in answering my questions. Thanks much,
    J
  8. by   core0
    Quote from jzzy88
    So, you say that nurses are only the eyes and ears of the physician and not the minds? Is this true?

    I'm surprised I haven't heard anyone say any different, perhaps it is true that nurses are just the handmaiden of the physician. What a big disappointment! And I suppose that the DNP is a waste of time!
    J
    I will have to disagree with this. Nursing involves a lot of independent consideration. We usually don't put parameters on meds but I would expect that the nurse would hold morphine if the BP was low. There are any number of examples where we rely on independent nursing judgment to keep the patient stable or to manage the patients condition. Nursing is an independent profession. Nobodies handmaiden.

    On the other hand nursing intentionally divorced itself from medicine with the advent of nursing diagnosis. Organized nursing made a decision to set themselves a part from medicine. However this also means that nursing diagnosis and to an extent nursing assessment became irrelevant to the medical diagnosis. You can't have it both ways - separate nursing diagnosis and input into medical diagnosis. Physicians (to include all providers) aren't going to learn a new system when they have one that works.

    As far as the DNP separate question. Nursing leadership seems to think that it will guarantee independence and other benefits. It really has nothing to do with bedside nursing besides trickledown benefits. Although you may be correct with your initial statement based on comments by NPs here.

    David Carpenter, PA-C
  9. by   silas2642
    Quote from jzzy88
    So, you say that nurses are only the eyes and ears of the physician and not the minds? Is this true?

    I'm surprised I haven't heard anyone say any different, perhaps it is true that nurses are just the handmaiden of the physician. What a big disappointment! And I suppose that the DNP is a waste of time!
    J
    Okay, I was lazy on my last post and didn't write enough. A good doctor will always listen to a good nurse and take her opinion strongly into consideration. When that nurse says, "I think you should give your pt., x med," chances are that pt. should be give x for a med. The nurse is the one who spends the time with the patient and is able to recognize the subtle little changes and quirks about the patient that the physicians just can't pick up on during the rounds in the morning. However, this doesn't change the fact that in the end, the physician has the last say in the final decision making.
  10. by   elkpark
    Quote from jzzy88
    So, you say that nurses are only the eyes and ears of the physician and not the minds? Is this true?

    I'm surprised I haven't heard anyone say any different, perhaps it is true that nurses are just the handmaiden of the physician. What a big disappointment! And I suppose that the DNP is a waste of time!

    Will getting a doctorate finally get people to stop assuming and treating nursing and nurses like morons? Will it validate nursing as a worthy pursuit?
    J
    What do you mean by nurses being "the mind" of the physician? Don't they have their own minds? They need us to be their "eyes and ears," since they spend so little time with the clients, but they certainly don't need us to be their minds. Savvy docs (or NPs or PAs) pay a lot of attention to what staff nurses have to say about their clients, but they (alone) are responsible for medical treatment decision-making and the outcomes of those decisions. As David mentioned earlier, it is v. foolish for any healthcare professional, nurse or doctor or any other practitioner, to base her/his professional decision-making (and, to be frank & realistic, the future of her/his career!) solely on someone else's observations.

    As for any great changes that the suddenly-much-vaunted DNP is going to make in how nurses are viewed, I predict it will have no effect whatsoever on people's view of generalist/undergraduate-level ("regular") RNs -- keep in mind that only a tiny, tiny percentage of RNs ever go on to pursue any type of advanced degree. (In fact, the majority of generalist RNs are ADN-prepared, which makes it very difficult for other professionals to take us (as a group) seriously ...) And perhaps it is very jaded and cynical of me, but my experience in healthcare over 20+ years, both as a generalist RN and as a CNS (only Master's prepared, of course, which I'm now being told is not good enough! ) is that other healthcare professionals are completely baffled by the educational process in nursing (diploma/ADN/BSN for entry into practice, MSN vs. PhD/DSN/DNSc/ND/DNP/DrNP/etc. at the graduate level), and so tend to form personal opinions about individual nurses based on how competent each individual nurse demonstrates her/himself to be in practice over time. I don't really expect that to change greatly even at the mid-level practitioner level if/when the doctorate becomes a requirement.

    I remember some nursing leader being quoted as saying, back when I was in nursing school in the Dark Ages, that one of the problems nursing faced as a group was that, "All nurses are expected to assume that all doctors are competent until proven otherwise, but each individual nurse has to prove her(/his) competence to each individual physician." Unfortunately, this phenomenon is largely still true today.

    I would say that (and maybe this is just me being jaded and cynical again) anyone going to into nursing expecting significant professional prestige and respect is probably going to be v. disappointed. That's not to say, however, that it isn't an interesting, rewarding, often exciting field. Whether or not it's a "worthy pursuit," however, it a matter of individual opinion.
  11. by   amzyRN
    Quote from elkpark
    What do you mean by nurses being "the mind" of the physician? Don't they have their own minds? They need us to be their "eyes and ears," since they spend so little time with the clients, but they certainly don't need us to be their minds. Savvy docs (or NPs or PAs) pay a lot of attention to what staff nurses have to say about their clients, but they (alone) are responsible for medical treatment decision-making and the outcomes of those decisions. As David mentioned earlier, it is v. foolish for any healthcare professional, nurse or doctor or any other practitioner, to base her/his professional decision-making (and, to be frank & realistic, the future of her/his career!) solely on someone else's observations.

    As for any great changes that the suddenly-much-vaunted DNP is going to make in how nurses are viewed, I predict it will have no effect whatsoever on people's view of generalist/undergraduate-level ("regular") RNs -- keep in mind that only a tiny, tiny percentage of RNs ever go on to pursue any type of advanced degree. (In fact, the majority of generalist RNs are ADN-prepared, which makes it very difficult for other professionals to take us (as a group) seriously ...) And perhaps it is very jaded and cynical of me, but my experience in healthcare over 20+ years, both as a generalist RN and as a CNS (only Master's prepared, of course, which I'm now being told is not good enough! ) is that other healthcare professionals are completely baffled by the educational process in nursing (diploma/ADN/BSN for entry into practice, MSN vs. PhD/DSN/DNSc/ND/DNP/DrNP/etc. at the graduate level), and so tend to form personal opinions about individual nurses based on how competent each individual nurse demonstrates her/himself to be in practice over time. I don't really expect that to change greatly even at the mid-level practitioner level if/when the doctorate becomes a requirement.

    I remember some nursing leader being quoted as saying, back when I was in nursing school in the Dark Ages, that one of the problems nursing faced as a group was that, "All nurses are expected to assume that all doctors are competent until proven otherwise, but each individual nurse has to prove her(/his) competence to each individual physician." Unfortunately, this phenomenon is largely still true today.

    I would say that (and maybe this is just me being jaded and cynical again) anyone going to into nursing expecting significant professional prestige and respect is probably going to be v. disappointed. That's not to say, however, that it isn't an interesting, rewarding, often exciting field. Whether or not it's a "worthy pursuit," however, it a matter of individual opinion.
    I think what I meant to say in my post was that I have my own mind and am not just a set of eyes and ears. That's frankly rather insulting. Everyone has their own mind, including the physician and his own eyes and ears as well. The eyes and ears better be connected to the mind or we are in big trouble here.

    Also, nurses aren't supposed to follow orders that don't make sense, so they have got to think. Anyone who just blindly follows orders shouldn't be in charge of other peoples lives. I wouldn't want some mindless set of eyes and ears as my nurse. I'd want a functioning brain between the ears.

    I also think that it is a collaborative effort between the health care team. Together we can make a difference in peoples lives. Doctors, nurses, NPs, PAs, can work together and respect each other.

    I'm a little worried now though about the prospects for myself in nursing. If even NPs are looked down upon, how can anyone stand it? Anyway, thanks for your post,
    J
  12. by   core0
    Quote from elkpark

    I remember some nursing leader being quoted as saying, back when I was in nursing school in the Dark Ages, that one of the problems nursing faced as a group was that, "All nurses are expected to assume that all doctors are competent until proven otherwise, but each individual nurse has to prove her(/his) competence to each individual physician." Unfortunately, this phenomenon is largely still true today.
    Nice post. I will take one portion (which I hope is not out of context).

    This is the essential problem with nursing assessment and nursing diagnosis. Nurses are professionals and as such should be allowed to manage their job in a manner which is appropriate. In theory nursing assessment and nursing diagnosis are part of that professional practice. However, nurses are employed by hospitals. Next to the Army (in my opinion) the most soul sucking organizations in the history of mankind.

    For my example. Look at a physician note. Mine are usually longer for billing purposes but this is a perfectly legal chart note:
    S: PT feels OK
    O: VSS afebrile
    Abdomen soft positive bowel sounds no MTO.
    A: Bacteremia - on antibiotics
    P: Follow

    Now look at a nursing assessment. These are usually multifold papers with hundreds of check boxes and places to write in nursing diagnosis. Even on computerized systems it is screens and screens of check boxes.

    Why do these exist. Originally it was a way to document nursing assessment and diagnosis. The checkboxes evolved because no one uses this and the interest is to get it out of the way. However, there is a darker and more sinister point here. Hospitals routinely use these not only to document nursing assessment but also to ensure that nurses are doing what nursing managers think that they should be doing. It is more important to document all the supposed interventions (whether they apply to the patient or not) than actually provide nursing care to the patient. Since nursing management doesn not have the ability to assess how the nurse is doing they use this as a surrogate. That is the true tragedy of nursing assessment.

    David Carpenter, PA-C
  13. by   DaisyRN, ACNP
    [font="comic sans ms"]
    in a word: "wow."

    lots of topics to discuss within this one little thread... *haha*

    let's look at an example:
    56 yr old english teacher presents to you with a stroke and irreversible focal neurological deficits. she cares for her 2 grandchildren in junior high school. her husband is deceased, and her nearest son lives 3 hours away... here's the difference in approach from medical vs. nursing...

    nursing diagnoses:
    1. caregiver role strain related to debilitating illness as evidenced by l sided hemiplegia... etc. (it's been a while since i've even thought about a nursing dx so bear with me... *lol*)
    2. impaired coping related to debility...etc.
    3. altered tissue perfusion related to immobility as evidenced by paralysis...
    4. risk of aspiration related to new illness as evidenced by difficulty swallowing and failed swallow study...
    5. fear..
    and the list goes on... (and on... and on...)...
    (here's a list if you're interested: http://www.everything2.com/index.pl?node_id=1014512)


    medical diagnoses:
    1. cva
    2. deconditioning (possibly)
    3. htn (maybe?)
    4. dmii (if she has it...)

    it's not that the nursing diagnoses aren't important, per se, but they are looking at how the medical diagnosis affects the patient's adls, quality of life, etc... and reminds the rn what he/she can do to help the patient cope with the illness, prevent aspiration, prevent decubitus ulcers, etc... not how to take care of the medical problem at hand. does that make sense? that is why the nursing assessment/diagnoses aren't relied upon solely for medical diagnosis and treatment. yes, it is the md/provider that orders social services consult, wound care, physical therapy, dietician, neuro consults, etc. and its the nursing assessment and conversations with the nurse (that has gotten to know the family/patient) that help guide these type of orders.

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