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.
I am constantly amazed by nurses who are so against the nursing process, fighting hard against making their own contributions to the care and recovery of the patient instead preferring to complete tasks and focus on following doctor's orders. The real sad part is that over and over again patient's suffer as nurses abandon the nursing plan of care......the basic care that makes the difference in how quickly and well a patient recovers.........to focus on medical care.......IVs, monitors and medications. So patients get respiratory treatments and IV antibiotics on time but nurses can't even be bothered to walk post-ops and encourage cough and deep breathing. It's too simple. All this effort fighting nursing diagnosis and plan of care is baffling, just baffling.
I am constantly amazed by nurses who are so against the nursing process, fighting hard against making their own contributions to the care and recovery of the patient instead preferring to complete tasks and focus on following doctor's orders. The real sad part is that over and over again patient's suffer as nurses abandon the nursing plan of care......the basic care that makes the difference in how quickly and well a patient recovers.........to focus on medical care.......IVs, monitors and medications. So patients get respiratory treatments and IV antibiotics on time but nurses can't even be bothered to walk post-ops and encourage cough and deep breathing. It's too simple. All this effort fighting nursing diagnosis and plan of care is baffling, just baffling.
I agree that there are too many nurses who focus on the monitors and the medications and forget about the deep breathing and coughing, the position changes, the mouth care, etc but I don't think that's what people are saying in this thread.
Nursing care comprising appropriate interventions for various patient problems and potential problems existed long before the introduction of nursing diagnosis. Care plans existed before the introduction of nursing diagnosis. You don't need wordy NANDA language to assess a patient, determine their needs and make a plan to address those needs. Why should we say 'activity intolerance' when that's caused by shortness of breath for example? It seems to be adding an unnecessary step. Doesn't it go without saying that a patient who is short of breath will have at least some difficulty with many activities? If we're thinking about a patient's hygiene needs, why should we say 'self care deficit' when the problem is that the patient has had a CVA? To me, the fact that the patient has had a CVA tells me a lot more about their probable needs than 'self care deficit' does.
I don't know, it could be that I'm too old school and just don't 'get it'. I'm enjoying the discussion anyway.
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.
Screening for risk factors that contribute to disease (diet, exercise, smoking, ETOH, hypertension, A1c, lipid panels) are also examples of primary prevention.
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.
I apologize if I twisted your words. What I was responding to was the assertion that we are not part of medicine. I do applaud that you do allow some aspects of the patient's plan of care to be based on the medical diagnoses/disease pathology.
"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.
off soapbox.
rather than stating the patient's diagnosis is:
"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)
you could just say "mi", which is not only more succinct, but contains far more information than the non-specific gobbleygook listed above. just because we don't use nd where i work by no means we don't use care planning. for an mi there are very specific and thorough standards of care, with the interventions tied to nic. but unlike the above example which are one size fits all, the standards of care for a stroke patient are different, which are different from the hf patient, etc. we then add other care plan sections customized to that patient; patient's a fall risk? we add well established standards of care for fall risk, same for risk for pressure ulcers, etc.
I am constantly amazed by nurses who are so against the nursing process, fighting hard against making their own contributions to the care and recovery of the patient instead preferring to complete tasks and focus on following doctor's orders. The real sad part is that over and over again patient's suffer as nurses abandon the nursing plan of care......the basic care that makes the difference in how quickly and well a patient recovers.........to focus on medical care.......IVs, monitors and medications. So patients get respiratory treatments and IV antibiotics on time but nurses can't even be bothered to walk post-ops and encourage cough and deep breathing. It's too simple. All this effort fighting nursing diagnosis and plan of care is baffling, just baffling.
NANDA terminology is not a requirement for the nursing process, and to me just impedes and works against the goals of a Nursing care plan (individualized, patient centered). Nursing interventions are not NANDA, that's NIC.
I don't think it's a lack of NANDA terminology that contributes to task oriented, in fact NANDA terminology tied to the NNN system is specifically designed to reduce nursing to an algorithm derived list of tasks. You just plug in the ND that the patient may fall in to, that gives you the NIC/NOC's and then that gives you your tasks. Temptingly well defined and standardized, but probably not good Nursing.
Who knows what the deal is, all I know is that I have not written plans of care anymore since I left nursing school in 1978. All the plans of care are standardized and we nix out the things that don't pertain to our patients-individualization. Of course I work in a patient care area where all patients are undergoing surgery. But even certain patient populations are given care maps that are specific for the procedure-ex. Hysterectomy, Total Hip and Total Knee, I believe there are care maps for pneumonia and MI. These are sanctioned by JCAHO and disease specific certification requirements. I am sure that there are nurses whose job is nothing but standardizing care plans and care maps, because the simple truth is there is not enough time to write care plans for all the patients you care for in one day. I think nurses have been very willing to let others do this work for them, because it is very time consuming and you can generalize diagnoses to a point. The onus for the nurse is on the one who first admits the patient to whatever care you are focused on. When I did home health we were required to do an overall assessment and then return to the office and write out a formal plan of care matching CPT codes. That was specifically for reimbursement and coverage from insurance/medicare/medicaid. If we didn't write everything down, the home health agency would not get as much money and treatments from nursing care, physical therapy and other entities would not be covered.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
I am constantly amazed by nurses who are so against the nursing process, fighting hard against making their own contributions to the care and recovery of the patient instead preferring to complete tasks and focus on following doctor's orders. The real sad part is that over and over again patient's suffer as nurses abandon the nursing plan of care......the basic care that makes the difference in how quickly and well a patient recovers.........to focus on medical care.......IVs, monitors and medications. So patients get respiratory treatments and IV antibiotics on time but nurses can't even be bothered to walk post-ops and encourage cough and deep breathing. It's too simple. All this effort fighting nursing diagnosis and plan of care is baffling, just baffling.
I don't hear people advocating for the idea that we get rid of a plan of care. I don't think a nurse would skip cough, walk, and deep-breathing because there was not a nursing diagnosis associated with it. I think the care plan has almost limitless potential and is indeed a "nursing only" thing we do.
Whatever else it may be I think sometimes the weak link between the care plan and the delivery of care is that there isn't a really effective way at the moment to make that care plan a "living thing" that is an interactive and easily accessible to everyone involved in the patient's care, and whether it was intended that way or not, the melding of NANDA and care plans made them less dynamic. I'm sure that the amount of resistance to NANDA has had a negative effect on care plans in general.
I remember the pre-nanda care plans had sections where information could flow the other way and be taken into consideration for modifying the care plan as the patient progresses (or not). I might liken that section of the care plan to the concept of "brainstorming" where the introduction of an innovative idea does not have to go through a long process or length of time before it is considered and either adopted or not.
It might be something as simple as a CNA writing down a tip or trick to feed a patient she noted and wanted to share. It was really an egalitarian concept and fostered the feeling of "team"-ness and mutual respect.
A while back on this thread I said I thought a Clinical Nurse Specialist in Nursing Dx would be a great way to teach resistant nurses how to implement them in real clinical situations and Green Tea arrived so I know that such a thing exists already! I don't think getting angry at nurses for their failure to embrace is that helpful but maybe Grn Tea can clone herself
I'm pretty sure the resistance is based on the feeling that at this point in time the nursing dx doesn't mesh well with their daily practice. It sounds like feedback has caused changes in the newer editions of NANDA guides - I honestly don't think too many people are aware of that, so they are still reacting to the models they learned in school.
I am constantly amazed by nurses who are so against the nursing process, fighting hard against making their own contributions to the care and recovery of the patient instead preferring to complete tasks and focus on following doctor's orders. The real sad part is that over and over again patient's suffer as nurses abandon the nursing plan of care......the basic care that makes the difference in how quickly and well a patient recovers.........to focus on medical care.......IVs, monitors and medications. So patients get respiratory treatments and IV antibiotics on time but nurses can't even be bothered to walk post-ops and encourage cough and deep breathing. It's too simple. All this effort fighting nursing diagnosis and plan of care is baffling, just baffling.
Hmmmm, IDK. I walk away from it with a completely different take on what the point is.
I fight things like ND and Care Plans SO I CAN do all the other things (IV antibiotics on time, walk post-ops, encourage IS and deep breathing). Where did the idea that since you don't like ND or CP's then you don't do these things come from? Not from this thread I assure you.
With rising acuity and the focus constantly being refocused towards paperwork (by administration and management, not nurses), bedside nurses frequently are put in a position of having to choose between good pt. care OR having all your T's crossed and I'l dotted. Most, not all, most nurses I know of choose to let the powers that be get their panties in a bunch and focus on pt. care. Doing both, perfectly and completely, would require staying hours late on a daily basis...............and these days, that gets you fired.
In short, the point is...............we want ND and CPs done away with because they contribute nothing to the process other than taking us away from the bedside, hence pt. care is sabotaged. How that got interpreted into preferring to complete doctor's orders and watch monitors is beyond me.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I am constantly amazed by nurses who are so against the nursing process, fighting hard against making their own contributions to the care and recovery of the patient instead preferring to complete tasks and focus on following doctor's orders. The real sad part is that over and over again patient's suffer as nurses abandon the nursing plan of care......the basic care that makes the difference in how quickly and well a patient recovers.........to focus on medical care.......IVs, monitors and medications. So patients get respiratory treatments and IV antibiotics on time but nurses can't even be bothered to walk post-ops and encourage cough and deep breathing. It's too simple. All this effort fighting nursing diagnosis and plan of care is baffling, just baffling.
*** Wow, just wow. You gathered that opinion form reading this thread? If so you have lept to wildly inaccurate conclusions without supporting comments from others that would justify such an opinion.
About to go to work, and something dawned on me: We as nurses don't use ONLY ND for our care plans at my facility. We have four CP's that must be done on each and every patient.................one of which is..........yep, the medical diagnosis.
COPD, bowel obstruction, DM, Hypertension, anemia, pneumonia............we got a care plan for them all.
Then there are the care plans for the ND stuff: Lack of knowledge, risk for fall, risk for impaired skin integrity.
Guess my facility is going to be reported to the academia police. Are we killing the nursing profession by using medical diagnosis this way? That's rhetorical btw.
The medical diagnosis leads to the nursing diagnosis which leads to the care plan. The nursing process is great, the nursing care plans are great- for students who are LEARNING to be nurses.
I agree that it is the disconnect between our forced care plans which are not used that is the problem. We make the care plans because we must, we document on them when we must, but we do not use them. Carepaths or Clinical Paths work better as do standards/protocols etc. and best practices.
We waste too much time on paperwork. It is one of the contributors to low productivity and high cost. One admission in home health can take most of a shift with all the involved paperwork. For one patient. Reimbursement does not even cover the cost. We must make multiple visits to recoup the massive paperwork cost, and for those patients who only need one visit, it is never recouped. This constant addition of paperwork is killing health care.
We need a paperwork reduction act for health care.
The medical diagnosis leads to the nursing diagnosis which leads to the care plan. The nursing process is great, the nursing care plans are great- for students who are LEARNING to be nurses.
I agree that it is the disconnect between our forced care plans which are not used that is the problem. We make the care plans because we must, we document on them when we must, but we do not use them. Carepaths or Clinical Paths work better as do standards/protocols etc. and best practices.
We waste too much time on paperwork. It is one of the contributors to low productivity and high cost. One admission in home health can take most of a shift with all the involved paperwork. For one patient. Reimbursement does not even cover the cost. We must make multiple visits to recoup the massive paperwork cost, and for those patients who only need one visit, it is never recouped. This constant addition of paperwork is killing health care.
We need a paperwork reduction act for health care.
Was it not, at one time, a "healthcare reform" issue to reduce paperwork and eliminate double charting?
Where did that go? IDK why, but I've said for a long time...............it seems people in healthcare don't take anything seriously unless it is writen in 10 different/completely separate places.
At a place I worked at, there was a task each shift had to perform. We created and "End of Shift Task Sheet" for the CNA's. This list showed everything they needed to know: Where the foleys were, who the blood glucoses were, who was NPO, who the incontinent patients were etc etc.
My problem with it was.................all that was handed off in a CNA to CNA shift handoff report AND was listed on their rounding sheets AND on a pt. care form in the front of the chart.
How many places does something have to be writen before it's considered valid? Is this a lack of an efficientl functioning communicaton system or what?
SharonH, RN
2,144 Posts
I am constantly amazed by nurses who are so against the nursing process, fighting hard against making their own contributions to the care and recovery of the patient instead preferring to complete tasks and focus on following doctor's orders. The real sad part is that over and over again patient's suffer as nurses abandon the nursing plan of care......the basic care that makes the difference in how quickly and well a patient recovers.........to focus on medical care.......IVs, monitors and medications. So patients get respiratory treatments and IV antibiotics on time but nurses can't even be bothered to walk post-ops and encourage cough and deep breathing. It's too simple. All this effort fighting nursing diagnosis and plan of care is baffling, just baffling.