Diagnosing versus identifying symtpoms

[OwlieO.O]

I'm a pre-nursing student (applying my second time this year) exploring concepts regarding nursing. I've recently began reading about the scope of practice with regards to CNAs, LPNs, and RNs. I'm trying to figure out a technical difference between identification of symptoms, and actual diagnosis. For example. I can easily identify an infected ear in my son, or a subconjunctival hemorrhage in a resident/patient I'm caring for. As a nurse, can I officially state, "patient has subconjunctival hemorrhage," or not? The difference between identifying dyspnea and diagnosing asthma is most apparent, but there seem to be grey areas in my understanding. What would be proper procedure if you believed your patient had a dissecting aortic aneurysm to state exactly what you believe it is, or that there's simply a cardiac event based on certain symptoms and activate the proper response?

[Guest219794]

Those I understand. Perhaps I'll reiterate my question - what is criteria for determining the difference between diagnosis and symptom? Like I stated - a physician could diagnose a fracture, but it seems silly that I couldn't state someone has a fractured tibia if, let's say, the pt suffers of a compound fracture and the tibia is staring you in the face.

Yup- You can state the patient has a fractured tibia. Why not? This is assuming your A and P skills are strong enough that you are sure it isn't the fibula.

As far as documentation? You calling it a fractured tibia adds nothing. Documenting that "1 inch of bone protruding through the anterior lower lug, 6 inches below the inferior aspect of the patella" is descriptive, and helpful.

And, to further make matters grey: Often, the chief complaint is the diagnosis, particularly in the ER. A pt whose chief complaint is shortness of breath, may, in fact, be diagnosed with shortness of breath.

I wouldn't worry too much about this. It really isn't an issue. Document what you see, hear, and do, and be descriptive and accurate.

[OwlieO.O]

By the way, as an example, what suggestions would you make to treat the underlying cause of asthma?

[SoldierNurse22, BSN, RN]

You could suggest that a patient gets allergy testing to see if there are triggers in their environment. They could also keep a journal of what they're eating to determine if there are triggers in their diets. Because exercise can be a trigger as well, patients might be mindful of how they feel/how often they need an inhaler when exercising. Of course, those suggestions wouldn't apply to someone diagnosed with pneumonia.

[jadelpn, LPN, EMT-B]

Nursing diagnosis and medical diagnosis are 2 completely different things.

A practioner (ie: MD, PA, NP) make medical diagnosises. Like "asthma" or "fracture"

Nurses, based on presentation make nursing diagnosises. Like "ineffective airway" or "alteration of health care maitenence".

Now, in SOME facilities (not all, but SOME) the RN creates the care plan with the nursing diagnosis, and the LPN would follow same. That is a generalization, but true for most acute care. (NOT ALL acute care but MOST). However, to be familiar with nursing care plans and nursing diagnosis, most LPN programs have you write your own in your clinical practice.

It is up to the practioner to decide how to treat the patient's asthma. Based on that treatment, it is up to the nurse to educate patient on same. Additionally, nursing care also includes the specific interventions noted in the nursing care plan per the nursing dignosises. This takes into consideration a number of things, which could include a discharge care plan, a care plan for the patient's health maitenence, that type of thing. Most practioners diagnose medically, and it is up to the nurse to take it from there to help the patient to function at fullest potential, and to provide feedback on whether these interventions are successful or need to be altered.

Hope that makes sense. But it is important to note that just because something presents as "obvious" doesn't mean it is. There can be a number of secondary issues that makes a "simple" diagnosis unclear. One of the best things about nursing care plans and nursing diagnosises is that it is multi-layered and can contain as many seperate functional issues as a patient would need.

[Esme12, ASN, BSN, RN]

Those I understand. Perhaps I'll reiterate my question - what is criteria for determining the difference between diagnosis and symptom? Like I stated - a physician could diagnose a fracture, but it seems silly that I couldn't state someone has a fractured tibia if, let's say, the pt suffers of a compound fracture and the tibia is staring you in the face.

The physician documents the diagnosis...you document what you see.

Patient has an open fracture to L leg.... obvious deformity noted to LLE. Large open wound, with bone exposed mid shaft 4 inches distal to the knee and 3 inches above the lateral malleous. distal circulation intact cap refill

You document what you see the MD determines the diagnosis based on the work up.

When sending a patient to the OR you have probably already have a work up. It's fine to say what the patient has signed the consent for and what the work up showed to the staff. You just document symptoms and that the patient went to the OR report to OR staff.

Your documentation should present a verbal picture that is detailed enough for someone to read it and KNOW what you ar taking about without actually naming it with a medical diagnosis.

Mr personally I wouldn't document subconjunctival hemorrhage...I would document my findings. Le the MD make the diagnosis that is what they get the big bucks for.

While you might KNOW what the patient has you describe their symptoms and what you observe on your assessment to develop a clear mental picture of the patients condition.

[Esme12, ASN, BSN, RN]

By the way, as an example, what suggestions would you make to treat the underlying cause of asthma?

What? what do you mean? treat the underlying cause of asthma on whom?

What is thier age? what are thier triggers? What do you mean by underlying cause of asthma?

[classicdame, MSN, EdD]

some terms can be confusing till you use them regularly. Nurses identify symptoms. You may "think" you have a medical diagnosis, but do not document such.

[Caffeine_IV]

I document symptoms and when I speak to the provider I relay the symptoms. If based on that I think I know what the patient has I may ask for certain things but I don't mention a diagnosis.

I talk diagnoses with my nurse colleagues and wait for confirmation or otherwise. When we are right, we pat ourselves on the back and file it in memory for future reference.

[psu_213, BSN, RN]

For the pt with asthma...the nurse would document "Pt reports shortness of breath. Appears to increased work of breathing. Wheezes auscultated in all lung fields." If the patient says "I think it's my asthma," you could chart "Pt states 'I think it's my asthma.'" [Of course, you would intervene as appropriate: breathing tx, call the doctor, etc.] Otherwise, the nurse would not chart "Impression: asthma attack"...that is a medical dx for the doctor to chart.

At that point, you are treating symptoms...i.e., opening up the airways so the pt can breath. In the long term, the underlying cause will get investigated/treated: do they have allergies? Should they be on a med that decreases inflammation in the lungs? Etc.

[psu_213, BSN, RN]

If you thought your patient had a dissecting aortic aneurysm, trust me, the last thing you would be doing is writing it down, or worrying about what to call it.

If you suspect a dissecting aortic aneurysm, you most certainly are going to move fast; however, someone still has to chart on the situation--even if it is after the pt has been taken to the OR...in that case you would chart "pt reports chest pain radiating to the back. Pt describes the pain as "ripping" in nature. Dr. So-and-so called. CTA of the chest ordered by Dr. Whomever. Pt to CT accompanied by RN, etc. etc." You would never mention dissecting aortic aneurysm unless that exact term is used by the pt or MD, in which case you could chart it as part of an exact quote.

[TrevyRN, BSN, RN]

Get good at describing things. It takes practice. And it's not just for conditions like asthma, but also for charting generally. For instance, if you walk into a room and a patient seems to have fallen out of bed, you don't put "pt fell out of bed". You put "pt found on floor, alert and oriented to person, place, time, and events. Does not complain of any pain or discomfort at this time. no visual or palpable injuries or abnormalities noted. Vital signs as follows...bla bla bla....Dr. Smith Notified." ... or something like that.

You are not a CT-scanner, X-ray machine, video camera, walking Lab, or otherwise. just use subjective and objective info to describe what's going on :-)

It's fun to play the "what's their diagnosis!" game in your head and then see if you're right after everything is said and done. You'd be surprised how often you're wrong with ones you think are obvious.

For instance, man comes in complaining of terrible unilateral flank pain... I'm like... kidney stone? vitals reveal he has a fever, WBCs elevated... so... Pyelonephritis? urine comes back fine... x ray comes back - pneumonia in one lower lobe. no complaints of trouble breathing, had good sats, lungs sounded decent. Guess i should have listened a little better instead of thinking about kidney stones...!

You'll get it in time. Pay attention to how fellow students, nurses, and teachers chart things. Try to pick up on others' good habits or steal their phrases and stuff...I MEAN ... ahem... allow their linguistic habits to influence your work. :-)

[dudette10, MSN, RN]

I too think you are overthinking it. As others have said, we don't diagnose nor document using diagnostic language. We describe s/s, what we've done to alleviate those s/s, and the patient response to the medical and nursing interventions that we've carried out. In the excitement of nursing school, you are focusing on (and confusing) the medical and nursing roles because you have little experience to differentiate the two and appreciate what we do as nurses that is not strictly medical.

You are focusing on the fun stuff...the emergent needs, rapid responses, critical changes requiring immediate treatment. Unless you work ER or ICU or other very high acuity units, 90% of the time, your patients are relatively stable. When you become a nurse, you'll see that we need to know the diagnosis, but our role is much more than treating a diagnosis. It is health promotion and discharge planning from the time they step foot into the hospital!

Example: a patient comes in with a critical low blood glucose, diabetic for years and years. Inpatient, we would monitor glucose and treat accordingly per orders. However, if that's the only thing we do, he would be back in the hospital in no time. Unfortunately, your assessment reveals that the patient doesn't check his blood glucose and doesn't know how to use his glucometer. You have the patient's family member bring in the home glucometer, and you teach him how to use it with return demonstration four times a day for ac/hs checks. You review his s/s that brought him into the hospital and point out that it is his body's reaction to a low blood glucose. You encourage him to check his blood glucose regularly and as needed based on the s/s he experiences. You promote adequate fluid intake, regular exercise, diet.

Another example: frequent flyer living at home with heavily involved family with daughter providing primary care at home...that wants things done her way. Pt nonverbal, generalized pain reaction at baseline, feeding tube, foley, central line, suctioning. Family throws a fit over how much free water is being infused through the g-tube. "We don't give that much!" Pt comes in with primary diagnosis of pneumonia, but is also hypernatremic. Just saying, "That's the order," isn't gonna fly because the family argues every order given. You have to educate about the relationship between hypernatremia and free water flushes. What's more is that this education increases trust (or at least decreases argumentativeness) among the HCWs and the family. The daughter will go home and google and see that we aren't all idiots out to make her dad sick.

Yes, the diagnosis is important for medical care. Teaching the patient/family how to prevent it from happening again or how to regain previous function is high quality nursing care. Our deep understanding of s/s, pathophysiology, medical treatments informs our health promotion education.