Confused Nursing Student

mediatix8 · Jan 21, 2007

Here's how this situation might play out in real life. Lets say this patient you are refering to is a new admission from the ER. To diagnose the flu all you do is a nasal swab and send it down to the lab and order an influenza screen. Chances are the ER is not stupid and all ready did this test on the patient so that by the time you get this admission you all ready know the results came back positive (influenza screen's are fast). All you would do is when you call the MD for orders you would inform him/her of the test results, go over and abdnormal labs if the ER hadn't all ready spoken with the MD, and ask for orders for meds the patient may need- tylenol for flu, perhaps something else for pain, definately a PRN for nausea. Maybe you would notice the ER MD ordered the fluids as ns @ 150cc/hr and you see the potassium was low so you might ask the MD if he might want to add potassium to the fluids. Doctor's miss things so you are there to ask for certain orders for things you see as needed. You definately play a critically thinking role here. By the way the docotr doesn't call down for the test results- it is you who calls the doc to inform of results.

So no, in a DIRECT way you are diagnosing things but in a way yes you do. Lets say the ER never did a nasal swab for influenza and you get the admission. When you call the doc you could be like hey don't you want an influenza screen? Also... for the patients you are taking care of you are there to notice any important changes and report them to the MD. A sudden productive cough and coorifice lung sounds- you are thinking pneumonia- you call the doc for a chest x ray, sputum sample, etc. Many times the doctor will order what you think they should order but sometimes they forget things and it's your job to remind them. A few times now I went into work (I work the night shift) and I would be looking at previous lab results from earlier that morning and notice a patient's potassium, for example, was pretty low and noticed that they were given a potassium rider (like an IV piggyback with potassiumn in it) and oh my the doctor didnt order a repeat potassium lab to see if it had improved for either the next am or after it was given. That's not right... someone forgot to recheck it! So then you order a repeat K level. Also, lets say you are called into a patient's room and they are freaking out and they show you their urine is blue! Are you going to call the doctor because of that? You have to think critically. Medications can change the color of urine. One of your patients used to be satting 95% on 4lNC and now they need a venturi mask at 50% o2 to sat at 95%. This occured on the previous shift and you ask the nurse if she notified the MD and she says no, explaining this also happened 3 days ago and only lasted a few hours and they were back on the 5L without problems...so it's not the first time this has happened. Besides, they are satting fine...are you going to call the doctor right now for a STAT abg? I would. So don't worry, you are not just giving out bankets and taking temps.

Epona · Jan 21, 2007

thanks Mediatix8! Those were very good examples. Good to know. See I was hoping we would get to do some medical related assessments as well. I am glad to see we get to do some in-depth medical diagnoses with the doctors. Very good to know.

Thanks for sharing!!! :)

MIA-RN1, RN · Jan 21, 2007

Epona, as Registered nurses we do NOT make medical diagnoses. Technically.

You check your patient, you note a fever, productive cough, cruddy lung sounds and you think maybe pneumonia. You call the doc, tell the doc the sx, and ask what he/she wants to do. If the doc says just fluids or whatever, you can say 'did you want to get an Xray?'

but your nursing diagnosis, what you chart in your note is NOT going to be that the pt seems to have pneumonia. Your dx is going to be along the lines of hyperthermia, impaired gas exchange, or something more relevant. The doc is the one who charts the diagnosis.

THe info you've gotten so far is correct but remember that you as a nurse are not a medical diagnostician. Youcan have your suspicions, and you will often be correct, but you can't order the labs yourself, or order the xrays, or chart your medical diagnosis. That is practicing medicine without a license.

It sounds tricky but it will get much more clear as you progress thru school.

Now, an APN such as an NP can and does make medical diagnoses and can and does order tests, xrays etc. But as a bedside RN, we can't do that.

clyen · Jan 21, 2007

As previously stated, as an RN we cannot give the medical diagnosis - if you do that you expose yourself to possible lawsuits. You may not have had a legal course yet for nursing - when I went through school we did, and the most important thing to remember is that you want to remain within the scope of nursing practice. If you start diagnosing medical conditions like a doctor or NP, then you can be sued at that level regardless if you are wrong or right. One of the most important roles we have as nurses is that, if we suspect pneumonia; we call the doctor and report our findings, suggest things the physician may not have ordered (for example, maybe he ordered the chest x-ray but forgot blood work), get IV fluids started and medications as ordered, and relaying information to the doctor so he/she can adjust the medications and other medical treatments (things that must be ordered by Dr or NP). While the nursing diagnoses and interventions may not seem as important, they really are. For example, impaired gas exchange and interventions to help this (breathing techniques for example) directly help the patient whereas a medical intervention (chest x-ray) may not.