Quote from Critical Care-Bear
I got into an argument with my physical assessment lab instructor and I want some feedback. Okay, we did the "ear, nose, throat" lab last week and my partners tonsils were swollen, she said her throat was sore and complained she wasn't feeling good. So in the write up we have to fill-out these sheets and on the back is a SOAP format, which means we have to list the subjective, objective, assessment, and I think the "P" is for plan of care or something, this is were we give the "diagnosis." So in the last part, I said I would collect throat cultures and send them to the lab to be examined to determine if the infection is bacterial or viral. Then I said that once I get the results I would suggest an antibiotic, such as azithromycin, if the infection is bacterial. If the infection was viral, I would recommend an anti-inflammatory agent or pain killer, such as aspirin, and remind the patient to drink plenty of fluids and get bedrest.
Anyway, next lab when I walk into class the instructor was going off about how we, as nurses, don't order medications. I knew she was talking about my paper. So before I sat down I said "well can't we suggest a course of therapy
or medication to the doctor?" She then said that we couldn't because the patient could be allergic to a particular medicine. I then told her that one of the first pieces of information we collect in an assessment is the patient's allergies. The teacher then kinda yelled at me and said, quite frankly, "YOU'RE
NOT A DOCTOR."
This is rediculous, Med-students only take 1 pharmacology course too. I've talked to med-students and they say that alot of the knowledge involved in prescribing a certain medication has to be learned on their own. Some nurses have 20 or more years of experience, I'm sure they can offer insight by suggesting medications to a Doctor. Am I wrong?
The teacher told me that what she was looking for was "nursing diagnosis's."
She suggested things like "adjusting the patients pillows." I'm not paying $500 a credit to learn how to fluff pillows! I want to be an active member in the healthcare process, not some ******* orderly. Does anybody feel me, or am I just going nuts? I think I'll get a prescription for xanax. This really gives me aggita. :angryfire
We've been doing SOAP notes and the Assessment is where you put your nursing diagnosis (Ex "Pain r/t red, inflamed tonsils") Then your P is your Plan, otherwise known as your therapeutic nursing interventions(Ex. Throat culture as ordered, warm gargle, prn pain meds as ordered)
You NEVER write a medical diagnosis in your note. You might say to the doc, yeah she looks like she might have strep, if the doc asks your opinion, but you NEVER medically diagnose. You can lose your license for that.
As far as fluffuing pillows, that is a nursing intervention, which you would do in response to your nursing diagnosis. You are helping the patient become more comfortable. You are not paying money to learn how to fluff pillows, and your instructor could have said it better, but you are learning how to help your patients and use your knowledge of nursing process to help the patient cope with illness etc.
I think like a nurse practitioner too, since I've worked with them for so long, and I tend to think about or try to guess what the medical diagnosis would be, but as a nurse you NEVER write it down and you never tell the patient a medical diagnosis without the doctor determining it first.