Medical Diagnosis Terms to Avoid

nurseprnRN, BSN, RN · Feb 15, 2014

So my lab instructor has us all freaked out about not using medical diagnosis terms/phrases in our narratives. Which I understand the legal, etc basis of, no issues with that part. However, due to her lack attention to detail in other areas of her instruction that I will not mention here, I feel it is necessary to double check when she says a term/phrase is "off limits" (i.e., a medical diagnosis).
Specifically, I'm wondering about nystagmus. It was my previous understanding that this is a descriptive term referring to involuntary tremors of the eye, and NOT an actual diagnosis. Please advise.
Also, this may be naive, but is there a database or reference book that I can use to check if a questionable term is/is not useable in nursing notes? Thanks.

You are correct about nystagmus. It is a term describing a particular physical examination finding and not a medical diagnosis. Nurses may -- must-- use such terms to improve their communication with each other and with other disciplines. Others are legion.

There is no such database or book. However, I think I can tell you where this comes from, and where it could lead, and make a a suggestion to head it off at the pass, as it were.

There are a number of misguided souls who assert that medical diagnoses cannot ever appear in a nursing diagnostic statement, e.g., (which means, "for example") anemia, CVA, fracture, surgery and their ilk. This is wrong, and the fastest and most definitive way to illustrate it is to take out your NANDA-I 2012-2014 and turn to any number of nursing diagnoses which do exactly that.

These people mean well, but they have become confused by another important problem when students are learning nursing diagnosis: The students often think that a nursing diagnosis ALWAYS relates to a medical diagnosis, that it MUST, and that is flat out wrong. You will see their error when you hear them ask us, "My patient has congestive heart failure and asthma, what are three nursing diagnoses?" Nursing diagnosis is not dependent on or subservient to medical diagnosis. There is no one-from-column-A-one-from-column-B list like that.

For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. THERE ARE MANY MORE. Don't you DARE use this list on your diabetic patient if you can't substantiate it from your own assessment. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

Many nursing diagnoses include medical diagnoses as part of the related to/causative factors. For example, "Pain" includes "injury agents (e.g., biological, chemical, physical, psychological)" and what is a physical agent that causes pain? Surgery, that's one. Biological? Don't "cancer" or "sickle cell anemia" fit that bill? You take my point.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

(Think any of these might apply to someone with a life-long, life-altering disease with many complications? :) Regardless of medical diagnosis?)

Now, if you are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Here.I.Stand, BSN, RN · Feb 15, 2014

I was taught not to use them as nursing dx or as their etiologies, but not that you can't use them in a narrative nursing note. They're being admitted for a subdural hematoma, not for abnormal intracranial sanguinous leakage. If I see nystagmus on my neuro exam, if writing a note about my neuro exam I say "nystagmus," not "fast, minute lateral bouncing of the globes."

KelRN215, BSN, RN · Feb 16, 2014

I worked in neuro for almost 5 years and I charted "nystagmus" probably almost every day. You can't make a medical diagnosis but that doesn't mean you can't reference medical diagnoses that have already been made.