i've been an adn for 16 years. recently, i finished my bsn and now am through my first year of a dnp program. like most students, i struggled with learning to understand a nursing diagnosis during my adn schooling. since that time the term has cropped up in various situations but usually as a passing comment. it has in no way benefitted my practice as a nurse. in fact, when i bring up the subject with colleagues i often get a smirk or an eye-roll!
the subject of nursing diagnoses happened to come up in one of my grad school classes the other day. i decided to take a stab at this sacred cow and suggest that maybe they are burdensome and irrelevant to a working nurse that they simply aren't utilized. my professor's response was a textbook explanation that i've only heard repeated on a college campus. "if you say your patient has pneumonia, you are using a medical diagnosis which is outside your scope of nursing practice. you must have a nursing diagnosis to be able to implement and evaluate your interventions." i may be wrong, but i'm pretty sure i've been able to implement and evaluate my nursing interventions without needing a nursing diagnosis.
personally, i believe the idea for a nursing diagnosis comes from the ongoing and hard-won independence from the thumb of the medical community. i am all for the continued growth of nursing science. however, on this point we overshot the mark. there is simply no justifiable rationale for calling pneumonia something like
"impaired gas exchange related to effects of alveolar-capillary membrane changes. or
ineffective airway clearance related to effects of infection, excessive tracheobronchial secretions, fatigue and decreased energy, chest discomfort and muscle weakness. "
why not just say the patient has pneumonia? because it a medical diagnosis and we don't practice medicine? baloney! its a pathologic condition. call it what it is. we dont need to reinvent the wheel.
why do we hang on to this? we need to eject it from nursing and maybe realize we don't use it like we thought we would. a lot of time and energy is wasted on this topic in nursing programs that could be better spent elsewhere.
My daughter has Celiac disease. She almost died from wasting away until a nurse diagnosed the problem.
Most doctors do not know what this disease is, much less how to treat it.
I took her to 7 doctors (including 2 GI docs) who all gave her the wrong diagnosis.
Just some of the diagnosis she received:
IBS and reflux - endoscopy, labs, and treated with medication and dietary change.
Chronic Migraine Headaches - CT scan, given anti-nausea and migraine meds
Beginning fibromyalgia (she had sever joint pain) - massage
Lactose intolerance - Lactaid and eventually taken off of dairy.
......and the list went on and on.
After $17,000 in doctor visits, procedures, scopes, and useless medicines, I took matters into my own hands and completely stopped listening to them. I did an extensive amount of research and used nursing treatments NOT medical ones to eliminate triggers, evaluate the problem, and then realized that it could be celiac. I called my pediatrician to do a simple blood test.
Her TTG level was 138. A person without celiac has a tTGA level of 0-4. For those of you familiar with celiac you know how high that level is.
I hear way too many people on this thread thinking that a doctor is always right and that a medical diagnosis should be the catalyst for our own care and treatment.
Again, as a nursing instructor, I will say that the ND and care plan systems need to be simplified, but that is the most effective way to teach nurses the difference between nursing and medicine and to also save a few lives in the process.
We have to have a care plan on every patient chart. As we do computer charting, it's not difficult as they are already in the system, we just check the appropriate boxes.
It's a total waste of time as the only times we look at the care plans is when we enter them early in the shift and at the end of the shift when we are supposed to check "in progress" etc. The care plan does not affect the care in any way. So why do them? They are now being updated in our Unit Based Council, but why bother? We are told it's another JAHCO thing!
With a nursing diagnosis, you are able to do interventions on your own regardless of the correct or incorrect medical diagnosis
.
Can you describe a situation where you would let a nursing dx trump the medical diagnosis?
Yes, one specific example:
My daughter has Celiac disease. She almost died from wasting away until a nurse diagnosed the problem.
Most doctors do not know what this disease is, much less how to treat it.
I took her to 7 doctors (including 2 GI docs) who all gave her the wrong diagnosis.
Just some of the diagnosis she received:
IBS and reflux - endoscopy, labs, and treated with medication and dietary change.
Chronic Migraine Headaches - CT scan, given anti-nausea and migraine meds
Beginning fibromyalgia (she had sever joint pain) - shoulder scope to R/O shoulder tear
Lactose intolerance - Lactaid and eventually taken off of dairy.
......and the list went on and on.
After $17,000 in doctor visits, procedures, scopes, and useless medicines, I took matters into my own hands and completely stopped listening to them. I did an extensive amount of research and used nursing treatments NOT medical ones to eliminate triggers, evaluate the problem, and then realized that it could be celiac. I called my pediatrician to do a simple blood test.
Her TTG level was 138. A person without celiac has a tTGA level of 0-4. For those of you familiar with celiac you know how high that level is.
I hear way too many people on this thread thinking that a doctor is always right and that a medical diagnosis should be the catalyst for our own care and treatment. In my case, the ONLY treatment for celiac disease is dietary, not medical. That is why medical intervention does not work.
Again, as a nursing instructor, I will say that the ND and care plan systems need to be simplified, but that is the most effective way to teach nurses the difference between nursing and medicine and to also save a few lives in the process.
You are putting down your own specialty by posting things like that.
A CNA might notice something like Impaired Skin Intergrity while giving a bath. A CNA cannot write the care plans, but can certainly contribute to their development.
When we enter a care plan into our computer program (which we are required to do on admission) it automatically generates nursing diagnosis that fit the physician's diagnosis (reason for admission). Once each shift, we are required to bring up this care plan and document on the outcomes. As a general rule, most of us do this at the end of the shift and it generally amounts to "Making progress" on nearly every one of them. Useful? I don't think so. Just something to put us into over-time.
I agree with the OP. I believe that about 90% of the time I wasted on this in nursing school would have been better spent in learning and practicing nursing skills.
In theory, competing diagnoses that focused on practice rather than disease were to help us compete head to head with other professionals. It just didn't work out that way, in part because of the cumbersome language you cited in your post.
"Impaired gas exchange" sounds a bit cumbersome, but there's no earthly reason it shouldn't be "due to pneumonia," especially if that is the patient's medical diagnosis. Or COPD. Or status asthmaticus. There is no earthly reason that nurses should be prevented from using the words in the already established medical diagnosis. It's just plain silly and everybody knows it but the ivory tower theoreticians who devised it all.
I could toss off 30 page care plans in nursing school with the greatest of ease. Out in the real world, we simply didn't do that sort of hoop jumping because we didn't have the time and this was a blatant waste of the time we did have.
It's high time for the whole business to be revisited and streamlined by nurses who have actually spent most of their time in the trenches, not by nurses who remain in academia creating elegant theories.
I totally agree. I have tried as a former educator to gently enlighten administrators and managers to the real world of trying to implement what they want you to do and it is virtually impossible in my environment. It is so cumbersome and fraught with redundancy that it forces work arounds and false documentation. People are operating out of fear of loss of reimbursement since all the JCAHO is tied to Medicare reimbursement, and that leads to private insurers following suit at a later date. We don't get to document what our nursing care really encompasses. I try to streamline things for mistake proofing, but only baby steps have been taken. If you try and find out what other nursing units have done upon transfer of patient care, it's like trying to read the Bible. Very difficult to interpret. I rely mostly on phone reports where the med/surg nurses document more accurately on their individual activity sheets they carry with them all day. Some of that documentation is not on the patient record in real time, so you have to bypass that record and go with the phone report. I think personally that memory is not to be relied upon. The documentation should be so plain that you can tell exactly what has been done and when it was done and who did it. Pages and pages of documentation don't tell you a thing. Like I said, it is taking baby steps to combine and get over the "knee-jerk" interpretations of what JCAHO and other entities want and be able to speak to the process that actually works for the nurses. Wow wouldn't that be something. People in academia think you have all this time to dot every I and cross every T but that doesn't happen in institutions outside of teaching facilities where you have a slower pace.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
nursel56
Yes, one specific example:
My daughter has Celiac disease. She almost died from wasting away until a nurse diagnosed the problem.
Most doctors do not know what this disease is, much less how to treat it.
I took her to 7 doctors (including 2 GI docs) who all gave her the wrong diagnosis.
Just some of the diagnosis she received:
IBS and reflux - endoscopy, labs, and treated with medication and dietary change.
Chronic Migraine Headaches - CT scan, given anti-nausea and migraine meds
Beginning fibromyalgia (she had sever joint pain) - shoulder scope to R/O shoulder tear
Lactose intolerance - Lactaid and eventually taken off of dairy.
......and the list went on and on.
After $17,000 in doctor visits, procedures, scopes, and useless medicines, I took matters into my own hands and completely stopped listening to them. I did an extensive amount of research and used nursing treatments NOT medical ones to eliminate triggers, evaluate the problem, and then realized that it could be celiac. I called my pediatrician to do a simple blood test.
I know that sometimes a diagnosis isn't made right away and that it can involve a long, frustrating and expensive process to get effective treatment.
I'm glad you were finally able to get her diagnosed and that she is feeling better. I went through utter hell with my daughter when she was in high school related to her asthma and food allergy situation. Prescriptions for "here, try this" over and over at $200 a pop for some of that "here, try this" stuff. So I have some very strong opinions about our healthcare system in general as a result of that.
I do not think your experience means that a "nursing diagnosis" was ever meant to be compared to a medical diagnosis as a matter of process for every patient who walks through the door. As far as I understand it, a patient would have a medical diagnosis and a nursing diagnosis, not a medical diagnosis or a nursing diagnosis. The very fact that you had to ask an MD to order the blood test for you illustrates one of the problems of making it either/or, and most MDs will not order tests just to help confirm a nursing diagnosis.
If we were to implement it system-wide (the only way it could be done to justify the billions all healthcare costs), we would have to subject the person coming in with strep throat or a broken ankle to the same nursing dx vs medical dx scrutiny that you went through with your daughter.
I hear way too many people on this thread thinking that a doctor is always right and that a medical diagnosis should be the catalyst for our own care and treatment. In my case, the ONLY treatment for celiac disease is dietary, not medical. That is why medical intervention does not work.
If an MD diagnoses a medical condition, and the treatment is dietary, he will counsel the patient to change their diet. I would say that if you feel the "nursing diagnosis" replaces the medical diagnosis it could be more accurately compared to other non-traditional therapies of which there are many. I don't believe that because one individual was helped by one of those after running the gauntlet it means it's a superior/inferior situation.
I mentioned a while back that I am not against the nursing diagnoses or other holistic modalities. The way they were originally conceptualized back in the 70s is not working. I am a bit stunned at the amount of heel-digging in by a vocal minority (not talking about you !) that continues in the face of mounting opposition by an ever-growing number of people from all walks of nursing life.
I had a horrible pinched nerve in my neck about 15 years ago and nothing worked for months. Finally on a whim I let one of of our MDs who also had been trained in chiropractic do an adjustment (ha ha I was humoring the guy...) and dang if that did not cure the problem but - should we get rid of ortho-docs? Hell, no! I just got lucky. Some chiros claim to cure cancer, too.
Again, as a nursing instructor, I will say that the ND and care plan systems need to be simplified, but that is the most effective way to teach nurses the difference between nursing and medicine and to also save a few lives in the process.
How would you simplify them? If you read through this thread you can't help but notice that well over 90% of working nurses find them a hindrance at best and the reasons are quite specific to their practice areas and administrative roles. That can not last. Several people have mentioned "workarounds" - nobody wants to have to come up with workarounds that will skew the results of the QA process and add un-needed stress to their lives.
:lol2:
:yeah:
Chaya, ASN, RN
932 Posts
More like the sacred BULL!!