Am I doing it the same way as you?

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Specializes in Mursing.

Hi, 3rd year BSN student from Canada here.

When working in acute care, we were taught to help patients in a systematic way. Assess, develop a plan, implement it, evaluate your interventions between goals and the actual outcome.

It seems as if I'm missing the "nursing diagnosis" step that alot of fellow students and nurses talk about on AllNurses.

Example: patient comes into the ER with SOB. I would assess the patient, get a health history, physical examination, etc. After collecting my data, let's say I determine that the reason why this patient has SOB is because of findings that suggest atelactasis (as an example). I would report this to the doc. The doctor would then go in, do his/her thing and come to a medical diagnosis and we'd continue treatment whether it be physio, meds, or something.

I never came to a conclusion of "SOB r/t atelactasis" or anything. So, am I missing the nursing diagnosis? Am I doing what you're doing but just in a different way? I'm so confused.

thanks!

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Specializes in Pediatric/Adolescent, Med-Surg.

You're doing exactly what nurses do. Once we're out in the field, we don't have formal careplans filled with nursing diagnosises for each pt. Instead, we're able to asses the pt, see what the problem is, and come up with a plan to help improve the problem, followed by re-evaluating to see if the plan worked. For nursing students, a formal care plan is nice to help them learn this process, but nurses know how to do the steps without having a formal nursing diagnosis. :nurse:

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I agree with the above poster. For nursing students the key nursing dx would be "impaired gas exchange" or "ineffective breathing pattern". Now, it's clear that you understand that those are issues, but with nursing student we have to write it all down. Not me anymore tho- I did my last careplan EVER 3 weeks ago! I graduate in 2 weeks! Sounds like you're right behind me. :nurse:

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I think you're lucky that you could learn nursing without having to take the extra, and what I consider to be unnecessary step, of formulating nursing diagnoses. It may help some people better understand the relationship between symptoms, pathophys, and nursing care but I think most of us could learn how to formulate effective and appropriate nursing care plans, and to understand and describe the rationales, without the formal nursing diagnoses that are taught in US schools. In fact, I think nursing diagnoses as they are taught some places can make things more confusing and take precious time away from other important learning opportunities while in school.

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Specializes in medicine and psychiatry.

I'm not terrible concerned as to why a patient is SOB. I'm mostly concerned with treating it. It is the Dr's job to diagnose. I can only theorize which is not difinative. If I think the Dr is incorrect I will state so and give a rationalle. If I think he makes a decision that is dangerous I can refuse. Ultimately I view my position as a supporting role for the Dr. I am the "hands on" of an often complex situation. Nursing diagnosis are helpful in assessing, planning, and implementing the steps to adress a situation. It is a useful teaching tool. As far as useful practical application on paper they are an annoyance. Updating care plans has been an issue at every institution I have worked. It often becomes an issue of time. Bedside nurses are pressed at the bedside so careplans often is not a priority. It is quite the dilema.

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I don't think that any nurse on the floor looks at some poor old guy who can't breathe and worries about a nursing diagnosis. You slap some O2 on him per orders, make sure he's in a good position for lung expansion, soothe him (people having trouble breathing get nervous) - and go from there. You know he can't cough up that gob of sputum and get in enough air. You need a nursing diagnosis for that? Nah.

Same as your old lady in bed with pneumonia. You need a plan to know that if you don't turn her and keep her bottom dry she's going to get skin breakdown?

Meh.

;)

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Specializes in med/surg, telemetry, IV therapy, mgmt.
Hi, 3rd year BSN student from Canada here.

When working in acute care, we were taught to help patients in a systematic way. Assess, develop a plan, implement it, evaluate your interventions between goals and the actual outcome.

It seems as if I'm missing the "nursing diagnosis" step that alot of fellow students and nurses talk about on AllNurses.

Example: patient comes into the ER with SOB. I would assess the patient, get a health history, physical examination, etc. After collecting my data, let's say I determine that the reason why this patient has SOB is because of findings that suggest atelactasis (as an example). I would report this to the doc. The doctor would then go in, do his/her thing and come to a medical diagnosis and we'd continue treatment whether it be physio, meds, or something.

I never came to a conclusion of "SOB r/t atelactasis" or anything. So, am I missing the nursing diagnosis? Am I doing what you're doing but just in a different way? I'm so confused.

thanks!

"Assess, develop a plan, implement it, evaluate your interventions between goals and the actual outcome" is problem solving. It is the way we wrote care plans years ago. Nursing diagnosis was introduced back in the late 70s to replace what the scholarly nurses felt many of us were constantly replicating on care plans. Before nursing diagnosis we just listed the symptoms we noted patients having like nausea and vomiting or edema. At that time, nobody cared if we were using medical terms to describe things we saw happening to patients and that we were doing nursing things for. But, you know us yankees--anal about this kind of stuff. You are pretty much doing the same thing we are, its just we've added that nursing diagnosis step just to make our lives miserable. You can tell, too. Just read the questions on the student forums--they all ask about the nursing diagnosis for this or that. I'm getting to believe that schools don't even teach the students how to properly diagnose. That or students aren't learning it properly. It's sad, really. Students end up terribly confused and hating care planning.

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Specializes in Critical Care.
I agree with the above poster. For nursing students the key nursing dx would be "impaired gas exchange" or "ineffective breathing pattern". Now, it's clear that you understand that those are issues, but with nursing student we have to write it all down. Not me anymore tho- I did my last careplan EVER 3 weeks ago! I graduate in 2 weeks! Sounds like you're right behind me. :nurse:

I hate to burst your bubble but you'll probably still be doing careplans as a nurse in some form or another. Nsg dx are one way we show how we do what we do. The interventions listed on care plans are frequently the interventions we do (many of us know to do without referring to a care plan). And you need to know JCAHO is always interested in looking at nursing documentation including care plans. So I wouldn't get too happy yet. I'm not a fan of care plans but have come to see them as a necessary evil. Unfortunately, a care plan can't reflect the critical thinking I do on my job every day or show the decisions I make. So sad.

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Specializes in Critical Care.
I'm not terrible concerned as to why a patient is SOB. I'm mostly concerned with treating it. It is the Dr's job to diagnose. I can only theorize which is not difinative. If I think the Dr is incorrect I will state so and give a rationalle. If I think he makes a decision that is dangerous I can refuse. Ultimately I view my position as a supporting role for the Dr. I am the "hands on" of an often complex situation. Nursing diagnosis are helpful in assessing, planning, and implementing the steps to adress a situation. It is a useful teaching tool. As far as useful practical application on paper they are an annoyance. Updating care plans has been an issue at every institution I have worked. It often becomes an issue of time. Bedside nurses are pressed at the bedside so careplans often is not a priority. It is quite the dilema.

I was reading your post and I guess I'm not clear on something. You said "I'm not terrible concerned as to why a patient is SOB" (citing the example). You mentioned it being more important to treat the pt and let the doc do the diagnosing. But how do you know to treat if you don't know or have an idea as to what is causing the problem? How do you prepare to do what must be done?

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Specializes in Mursing.

Thanks for clarifying everything up for me! I thought I was missing a critical step in my education. It seems as if we're all taught the same thing just differently. Thanks!!!

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