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.
What do you do when your patient does not have a medical diagnosis?
The 40% of Nurses who work in non-hospital settings; mainly LTC, clinics, home health, and tele-health, are by no means immune from dealing with conditions that would fall under 'medical' diagnoses. There are some issues that aren't covered a 'medical' diagnosis which is were patient-specific problem statements are best used. Taking a description of a patient's problem (or potential problem) that is specific to that patient and re-wording it as a generic description is counter-productive and serves no beneficial purpose. For instance; a patient who doesn't like to take their lasix because it disturbs their marathon sessions of online game playing. Does "patient is non-compliant with lasix due to the interference of frequent urination with online gaming" better describe the situation to other caregivers or does "knowledge deficit related to medication"/"ineffective health care maintenance" better describe it? Which description is more likely to produce the more patient centered and effective interventions? Why take a patient specific description and water it down to the point of relative uselessness? You can't accurately communicate the patient's problem with a Nursing diagnosis, and you can't prioritize correctly based on the Nursing diagnosis either. Impaired gas exchange may sometimes trump deficient knowledge, but not if the impaired gas exchange is due to a cold in an otherwise health patient and deficient knowledge refers to the patient's belief that they are supposed to take 10 warfarin pills daily instead of one 10mg pill daily. Again, you have to look at the actual problem, not what billing category that problem might fit into if required to try and put a round peg in a square hole by the billing department. We should always work towards more individualized and accurate descriptions of a patient's problems, not less, which is what ND's do.
I see us a health care profession. I try and prevent disease instead of just healing someone after they have obtained one.
'Health care- professions include medical (those in patient care) and non-medical (billing, administration, central supply, biomed, etc). Being a key player in the "art and science of healing", we are part of the medical team, not part of the non-medical side of healthcare along with the housekeepers, although we seem intent on making the case for that. It's not hard to understand why the public is confused about what we do. You have to remember that the common definition of 'medicine' includes everything from what Physicians do all the way to Reiki on the other end of the spectrum. There's homeopathic medicine, naturopathic medicine, holistic medicine, alternative medicine, complimentary medicine, etc. So when we say we aren't a type of any medicine, it's not surprising that people are left scratching their heads about what it is that we do given the wide range of patient care methods that are considered "medicine".
While it's certainly important to communicate that Nursing includes a wider or at least different range of ways to view and treat the patient than that of a Physician, I don't think making that point by downplaying the role we play in the Physician's contribution to the patient's plan of care is beneficial. Nurses play a key role in planning, implementing, educating, and evaluating the Physician's portion of the plan of care. An implied denial of this involvement related to the 'medical' diagnosis is essentially denying the majority, if not all, of the perceived value of Nursing care held by the general public (and more importantly CMS).
To say that Physicians only treat someone after they have obtained a disease is absurd. How do you explain routine physicals? Immunizations? Colonoscopy screenings? Prostate exams? Breast exam screenings? Routine lipid panels? Why does my Doctor ask me about my diet, exercise, smoking during check-ups?
The paradigm is similar to that of DO vs MD. The DO's had to invent something "new" to give themselves plausability & credibility. Of course, we all know DO's are folks who couldn't get into medical school.
I believe nursing would actually benefit from more emphasis on SCIENCE and less on the psychobabble aspect. It hurts your credibility as a "profession."
I believe nursing would actually benefit from more emphasis on SCIENCE and less on the psychobabble aspect. It hurts your credibility as a "profession."
The problem with that is in the new thing regarding Press Ganey scores. Patients are starting to expect us to provide a spa-like atmosphere and the science we use to actually help them get healthier be damned. IF the food is hot and 5-star, the scores will be better than if the food is warm and they were discharged a day earlier than expected.
To say that Physicians only treat someone after they have obtained a disease is absurd. How do you explain routine physicals? Immunizations? Colonoscopy screenings? Prostate exams? Breast exam screenings? Routine lipid panels? Why does my Doctor ask me about my diet, exercise, smoking during check-ups?
The above examples are not primary prevention except for immunizations, they are examples of secondary prevention. I don't see too many physicians out in the community doing primary prevention which is one of the classes I teach.
I don't think making that point by downplaying the role we play in the Physician's contribution to the patient's plan of care is beneficial. Nurses play a key role in planning, implementing, educating, and evaluating the Physician's portion of the plan of care. An implied denial of this involvement related to the 'medical' diagnosis is essentially denying the majority, if not all, of the perceived value of Nursing care held by the general public (and more importantly CMS).
I never said we shouldn't work with physicians or plan care with them. Please stop twisting my words. Again, let me say this again, I think we bring a lot to the table and we should also look at the patient from another point of view.
The paradigm is similar to that of DO vs MD. The DO's had to invent something "new" to give themselves plausability & credibility. Of course, we all know DO's are folks who couldn't get into medical school.
The 6 docs who misdiagnosed my daughter's illness were all MD's. The doc who finally listened to my husband and I and saved her life was a DO.
My husband is an MD (who knowledge was also essential for my daughter's dx). He has 8 MD's and 2 DO's in his group. Most people, even docs themselves cannot tell the difference.
First off, thanks for the interesting & civil dialogue! Lots of food for thought!
The 6 docs who misdiagnosed my daughter's illness were all MD's. The doc who finally listened to my husband and I and saved her life was a DO.
Are you suggesting, though, that nurses would have been more likely to figure out the cause of the illness? Are you suggesting that "the nursing process" (and the DO process, presumably?) is more likely to yield an answer than "the medical diagnostic process"? If so, when those few holistic MDs incorporate a more holistic approach into their assessment & diagnostic process, are they then applying the nursing process (or DO process) ? I don't think so.
I'd argue that the nursing process (in the broadest defintion) *is* a holistic health care assessment that drives a plan of care (APIE). Teachers also must do holistic assessments of their students, considering home conditions, psychological issues, etc in order to fully address their students' needs. Ideally physicians would do holistic assessments.
The medical diagnostic process is simply the diagnostic process applied to health conditions. The diagnostic process is also utilized by mechanics attempting to determine why the engine "is making a funny noise." This is where ND fail.
There is no diagnostic process in determining ND. To me, diagnosing is attempting to determine why something is different. Why is the pt experiencing chest pain? Maybe it's cardiac ischemia. Maybe it's indigestion. ND seems more like a translation of the subjective and objective *assessment* data. Assessment: pt can't dress self (dressing self is self care and the patient has a deficit) = self care deficit. How is that a "diagnosis"?
Maybe just getting rid of the word "diagnosis" in ND would help matters - a formal *typology* of nursing considerations DOES make sense to me. To ensure nurses are covering all bases, they can make sure that they address all of the typologies relevant to their area of practice - self care, fluid/volume balance, nutrition, etc. Hmm... what to call it? Calling this categorization a nursing diagnosis, just seems to confuse things - at least for me - and apparently my instructors - and many other nurses!
Are you suggesting, though, that nurses would have been more likely to figure out the cause of the illness?
Yes, I am the one who figured it out.
Are you suggesting that "the nursing process" (and the DO process, presumably?) is more likely to yield an answer than "the medical diagnostic process"? If so, when those few holistic MDs incorporate a more holistic approach into their assessment & diagnostic process, are they then applying the nursing process (or DO process)
The docs came in and applied a medical model and when they could not find out what it was, they basically gave up. It took a holistic approach to find out what it was. I discovered it myself, but since I am not a doctor, I had to call the pediatrician and ask him to order a celiac panel. I could have just taken gluten out of her diet and she would have had the same results, but then we would have never had a positive answer. I started from scratch, assessed the situation, thought of a couple of ND, eliminated all food from the diet and started with ensure and added new foods in. Based on my observations, I had my answer in a few days. One MD said he "couldn't just go around ordering celiac panels based on a whim" (which was a complete joke since she had 11 of the symptoms), but the DO listened to all my concerns, looked up the disease for more review and realized how common it is. The medical community has all but ignored it because there is no medical cure for it, only dietary treatment.
But maybe we have some common ground here. If you don't want to call it diagnosis, I have no problem with that. I am not holding onto that word. But IMO the nurses who only want to use a medical diagnosis from which to base their care are not providing their patients total care. They are there to be the patient's advocate and sometimes that means challenging the doc and figuring some things out on your own.
we've gotten so far off track. You must have some reasoning for beginning nursing treatment. When a patient is first assessed you base your nursing intervention based on a list of diagnoses. All that was said in the start was, could the diagnosis language be a little more simple? Could it be in a language that is not so wordy? It has nothing to do with what doctors diagnose etc. That part of taking orders is a given no matter what you think. Nurses can do alot without doctors diagnosing a thing. The main thing is that coordination of care is done and that is the nurses responsibility.
we've gotten so far off track. you must have some reasoning for beginning nursing treatment. when a patient is first assessed you base your nursing intervention based on a list of diagnoses. all that was said in the start was, could the diagnosis language be a little more simple? could it be in a language that is not so wordy? it has nothing to do with what doctors diagnose etc. that part of taking orders is a given no matter what you think. nurses can do alot without doctors diagnosing a thing. the main thing is that coordination of care is done and that is the nurses responsibility.
yes. most certainly. i agree here.
i've been in this....eh, mood/mindset that along the way, we as nurses lost our way. we became so focused on defining ourselves as a profession, we completely lost contact with our core value.........patient care.
for entire generations, we have walked in the same direction with the same definitions of what nursing's "unique body of knowledge" truly is and we find ourselves butting our head against the same wall over and over and over again. at large, we are still viewed as a labor, not a profession (with the exception of those within our own ranks) but for some reason, we insist on walking into the same wall we were walking into generations ago and we think, someday, magically, the general public and our fellow healthcare workers will notice the bleeding knot on our forehead and wake up, all of a sudden proclaiming "nursing is vital for our operations."
when they don't take notice though, we take on the form of catty backstabbing administrators and start in with all the other bad habits nursing has come to embrace. physician slamming (my personal most hated bad habit), attributing things to nursing (illness prevention) to nursing and claiming we are the only one's who get it and of course, another one of my favorites, jumping on the "moral higher ground" train as if everyone else has an agenda against us.
maybe the answer is: instead of waiting for everyone else to take notice of our nd and care plans etc etc...........just perhaps we need to take notice of the fact that everyone else is ignoring us, and probably with good reason. could it be that, perhaps, our attempts at defining what it is that makes us unique simply don't cut the mustard and it is time to go back to the drawing board?
that is exactly where i am with all of it anyway. i do feel that people in general, both in and outside the healthcare field, do not have a clear understanding of the nurses role in healthcare nor a way of appreciating its value to the overall healthcare process.
that's our won fault folks. nobody else's. its our duty and problem to promote our own profession. we have not done it. wordy nd and care plans aren't getting anyone's respect.........heck, look at this thread, even nurses don't respect it.
i'm sorry to say msn10, that is where i disagree with you. you seem to be intent to hold onto an old/outdated system (nd) that in effect contributes nothing and has failed on every level. we agree on the end point, but not at all on how to get there. for me, with the end point being "better patient care" and "educate the public on nursing's unique role within the healthcare team".................step #1 is doing away with nd and other such unnecessary old school theories/systems that have, up to this point, failed us.
I'm watching Star Wars, "A New Hope" as I wrote the last post. I'm going to do an "original series" marathon today.
Well, sure nuff...........as I finish my last post with all the jazz about doing away with ND, what scene comes on the tube?
Imperial General: "Don't try to frighten us with your sorcerer's ways Lord Vader. Your sad devotion to that ancient religion has not helped you conjure up the stolen data tapes or given you clairvoyance enough to find the rebel's hidden fort................[chocking in the middle of the word fortress, chocking worsens, the general can't breath at all]."
Darth Vadar: "I find your lack of faith in me disturbing." [Continues to choke the General from across the room, using this Jedi powers, seems intent on letting the general die from lack of oxygen]
Higher Ranking General: "Enough of this. Vadar...........release him".
Darth Vadar: "As you wish" [chocking stops]
Hmmmm..............should I have the ambulance on speed dial after my last post?
I wonder: Did the "Higher Ranking General" use ND? He saw the "Ineffective Airway Clearance" and thought to himself......"Oh bother, I don't want to fill out all the paperwork for another victim of Vadar's chocking. Perhaps I can talk him out of it."
:eek:Is it possible, the Generals in the Imperial Army are all nurses? Is this the future we want?
I'm sorry to say MSN10, that is where I disagree with you.
Totally fine, I like debating topics with you.
You seem to be intent to hold onto an old/outdated system (ND) that in effect contributes nothing and has failed on every level. We agree on the end point, but not at all on how to get there. .............step #1 is doing away with ND and other such unnecessary old school theories/systems that have, up to this point, failed us.
However, I am not 'holding onto' anything, I just use it along with other things. I would do my students a disservice if I did not talk about it because some places that my students will work at do still use this approach.
Also, if you want to do away with something like ND that is fine with me, as long there is something better and universally applicable and accepted to replace it. One thing I teach is IT in nursing and sooner than later we are going to have charting which can be accessed by many other institutions and practitioners. Right now, docs can universally communicate by diagnosis and treatments. We need to be able to do the same.
"as nurses, the medical diagnosis is not of our concern, only the generalized response to the disease, implying that as nurses we view patients having an mi, a hemorrhagic stroke, pad, diabetic neuropathy, and reynauds all the same since they are just "impaired tissue perfusion" patients. while in reality, to fulfill the needs of our patients, not to mention our legal responsibilities; how we assess, plan, intervene, and evaluate each of these patients must differ significantly based on the specific physiologic process affecting the patient (aka: medical diagnosis)."
this attitude characterizes and bespeaks an impoverished (and poorly-fed) concept of nursing diagnosis. you think your mi, cva, psd, dm neuropathy, and rd people are only "impaired tissue perfusion," as if that means you can only think of all these different people in one way, and only conceptualize all of their care in one limited fashion, and limit yourself to one set of nursing responses to them. i am sure you know enough about nursing so you don't really do that, so let me show you how you would use nd for all of them (and how a new nurse might learn about new ways to look at nursing all those different people).
i'll bet you haven't seen the 2009-2011 nanda book. it is not not not the nd book you had in school, i promise. i know you haven't, because you won't find "inadequate tissue perfusion" as a single diagnosis. you will find things that relate to that, and you will find a lot of them that relate to one or more of your laundry list of medical diagnoses (with things related to every medical dx to look at and deal with from a nursing perspective)
fatigue (can be related to anemia or lousy bp or ... , anyone?)
activity intolerance (you can figure what medical dxs that one can be related to)
risk for bleeding
decreased cardiac output
ineffective peripheral tissue perfusion
risk for decreased cardiac/cerebral/renal/or gi tissue perfusion
risk for shock
self care deficits (several) ( can be related to lots of things, including decreased tissue perfusion from a variety of medical diagnoses, of course)
i dare you to read this and not be inspired about the work that went into documenting nursing's very specific and scientifically-based interventions and value in care of patients with any sort of medical diagnosis-- and the people who do it at the bedside every day. it's sooo trendy and pseudosophisticatedly high-sounding to diss nd if you don't see what it does for your autonomy-- unless you're so stuck on tasks and checklists that you can't think that much about the rationales for what you do.
MunoRN, RN
8,058 Posts
The 40% of Nurses who work in non-hospital settings; mainly LTC, clinics, home health, and tele-health, are by no means immune from dealing with conditions that would fall under 'medical' diagnoses. There are some issues that aren't covered a 'medical' diagnosis which is were patient-specific problem statements are best used. Taking a description of a patient's problem (or potential problem) that is specific to that patient and re-wording it as a generic description is counter-productive and serves no beneficial purpose. For instance; a patient who doesn't like to take their lasix because it disturbs their marathon sessions of online game playing. Does "patient is non-compliant with lasix due to the interference of frequent urination with online gaming" better describe the situation to other caregivers or does "knowledge deficit related to medication"/"ineffective health care maintenance" better describe it? Which description is more likely to produce the more patient centered and effective interventions? Why take a patient specific description and water it down to the point of relative uselessness? You can't accurately communicate the patient's problem with a Nursing diagnosis, and you can't prioritize correctly based on the Nursing diagnosis either. Impaired gas exchange may sometimes trump deficient knowledge, but not if the impaired gas exchange is due to a cold in an otherwise health patient and deficient knowledge refers to the patient's belief that they are supposed to take 10 warfarin pills daily instead of one 10mg pill daily. Again, you have to look at the actual problem, not what billing category that problem might fit into if required to try and put a round peg in a square hole by the billing department. We should always work towards more individualized and accurate descriptions of a patient's problems, not less, which is what ND's do.
'Health care- professions include medical (those in patient care) and non-medical (billing, administration, central supply, biomed, etc). Being a key player in the "art and science of healing", we are part of the medical team, not part of the non-medical side of healthcare along with the housekeepers, although we seem intent on making the case for that. It's not hard to understand why the public is confused about what we do. You have to remember that the common definition of 'medicine' includes everything from what Physicians do all the way to Reiki on the other end of the spectrum. There's homeopathic medicine, naturopathic medicine, holistic medicine, alternative medicine, complimentary medicine, etc. So when we say we aren't a type of any medicine, it's not surprising that people are left scratching their heads about what it is that we do given the wide range of patient care methods that are considered "medicine".
While it's certainly important to communicate that Nursing includes a wider or at least different range of ways to view and treat the patient than that of a Physician, I don't think making that point by downplaying the role we play in the Physician's contribution to the patient's plan of care is beneficial. Nurses play a key role in planning, implementing, educating, and evaluating the Physician's portion of the plan of care. An implied denial of this involvement related to the 'medical' diagnosis is essentially denying the majority, if not all, of the perceived value of Nursing care held by the general public (and more importantly CMS).
To say that Physicians only treat someone after they have obtained a disease is absurd. How do you explain routine physicals? Immunizations? Colonoscopy screenings? Prostate exams? Breast exam screenings? Routine lipid panels? Why does my Doctor ask me about my diet, exercise, smoking during check-ups?