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.
Yes, they are still working towards electronic records, but they are fighting through HIPAA and it will not reduce our required documentation- it will only allow everyone to share the record. The OASIS and care plans, teaching sheets, thousands of consents, yada yada yada will still be with us until they can do something to reduce the need to protect ourselves from lawsuits. That is the only reason we do half this stuff.
Again, what about the fact that the use of the term 'diagnosis' in ND only further muddies the water?
A cancer pt undergoing chemo has thrown up after eating several times. ND: Altered nutrition (or pot'l for). How did we 'reach that conclusion'? If someone is having trouble keeping food down then they aren't taking in as much nutrition as they would otherwise. Brilliant! 1+1 = 2 is not the diagnostic process.
Pt had a hip replacement yesterday. ND: Impaired mobility. Is there any possible way someone with a hip replacement yesterday would NOT have impaired mobility?
Pt is having loose stool. ND: Diarrhea. Assessment = diagnosis.
Yes, there are extenuating concerns r/t to the problems, but it still confuses matters to me to use the label 'diagnosis'.
A pt with impaired mobility may also be likely to be a fall risk. How does one determine that? By doing an assessment and pulling upon one's knowledge of the particular mobility impairment, not by using the diagnostic process.
A pt with diarrhea may be at risk for fluid volume deficit. How does one determine that? *Any* pt with diarrhea may be at risk for fluid volume deficit. Who is more at risk? An assessment would give valuable in addition to knowledge of the pt's known medical conditions. No use of the diagnostic process there.
The only thing I hate about these threads is that people can come off sounding snarky when they don't mean to be. That is the last thing I want to do so please read my questions with the idea that this is a very interesting subject to me and I am looking to further nursing education, not argue.
Again, what about the fact that the use of the term 'diagnosis' in ND only further muddies the water
A diagnosis is the process of classifying a problem. "Activity intolerance, Risk of shock, etc.," seem like significant problems. Is there another term you would use to describe the problem? You said that :
A pt with impaired mobility may also be likely to be a fall risk. How does one determine that? By doing an assessment and pulling upon one's knowledge of the particular mobility impairment, not by using the diagnostic process.
Isn't an assessment the first step in the diagnostic procedure?
Doctors take in all of the information (assessment) and then diagnose the problem. Assessing the patient's gait is just that, and assessment. The conclusion of the assessments is the diagnosis. Since doctors don't practice nursing, they don't diagnose in our scope of practice. We try to help the patient not only by performing medical tasks: med pass, foley insertion, etc., but we also are assessing their environment and treating their symptoms as well, hopefully with something other than just meds.
Truth is, anyone can pass a medication (that is why they have med techs in some states) or do an EKG or foley placement (CNAs have been trained to do that.) But nurses are unique because of their assessment, diagnosis, and planning, and the evaluation of care to make a determination if that care is working or not. Then said nurse reports findings to fellow nurses, doctors, as well as other health care professionals to change or keep plan of care going.
What I think is lost is that when you are a really good nurse (or expert nurse as Benner believes), you do this kind of stuff in your head and writing it down seems cumbersome. When we look at a hip replacement or MI patient, we automatically think this patient is going to need nursing interventions a, b and c because we were trained that way. But we have to assess them and diagnosis what impairment they actually have. One MI patient may be on death's door while another might not even know they have had an MI. One may have to have their chest cracked open while the other might be put on meds. They need 2 totally different plans of care and that is why a medical diagnosis is not always enough. Their symptoms and reactions to their medical diagnosis have to be assessed and diagnosed.
The ND was a way to classify the impairment in the first place - to communicate the patient's problem in one statement.
Sorry it is off topic but when doing a ND in a community setting, there is a difference.
Screening for risk factors that contribute to disease (diet, exercise, smoking, ETOH, hypertension, A1c, lipid panels) are also examples of primary prevention.
Primary Prevention: "Relates to activities directed at preventing a problem before it occurs (Keller et all., 2004). Dietary teaching during pregnancy, smoking prevention education, fluoride water supplementation, immunizations. Screenings such as mamo, lipid panel, lead screening exams, are secondary because you are looking for problems that are already there, not prevention.
Secondary Prevention: Any type of screening. Refers to early detection before signs and symptoms have begun and targets populations with certain risk factors. Secondary activities include Mammography, blood work, blood pressure screening, pap smear, smoking cesation, vision screening, dental exam, etc. (Keller, 2004; McEwen and Pullis, 2008).
The only thing I hate about these threads is that people can come off sounding snarky when they don't mean to be. That is the last thing I want to do so please read my questions with the idea that this is a very interesting subject to me and I am looking to further nursing education, not argue.
A diagnosis is the process of classifying a problem. "Activity intolerance, Risk of shock, etc.," seem like significant problems. Is there another term you would use to describe the problem? You said that :
Isn't an assessment the first step in the diagnostic procedure?
Doctors take in all of the information (assessment) and then diagnose the problem. Assessing the patient's gait is just that, and assessment. The conclusion of the assessments is the diagnosis. Since doctors don't practice nursing, they don't diagnose in our scope of practice. We try to help the patient not only by performing medical tasks: med pass, foley insertion, etc., but we also are assessing their environment and treating their symptoms as well, hopefully with something other than just meds.
Truth is, anyone can pass a medication (that is why they have med techs in some states) or do an EKG or foley placement (CNAs have been trained to do that.) But nurses are unique because of their assessment, diagnosis, and planning, and the evaluation of care to make a determination if that care is working or not. Then said nurse reports findings to fellow nurses, doctors, as well as other health care professionals to change or keep plan of care going.
What I think is lost is that when you are a really good nurse (or expert nurse as Benner believes), you do this kind of stuff in your head and writing it down seems cumbersome. When we look at a hip replacement or MI patient, we automatically think this patient is going to need nursing interventions a, b and c because we were trained that way. But we have to assess them and diagnosis what impairment they actually have. One MI patient may be on death's door while another might not even know they have had an MI. One may have to have their chest cracked open while the other might be put on meds. They need 2 totally different plans of care and that is why a medical diagnosis is not always enough. Their symptoms and reactions to their medical diagnosis have to be assessed and diagnosed.
The ND was a way to classify the impairment in the first place - to communicate the patient's problem in one statement.
OK
Finally. A concrete example/argument for ND having some value. Now that is the stuff that speaks to me and gets my gears whirling.
I still struggle with "the need to create a language for nurses to communicate in" stuff. My choice is English......its worked very well for me up to this point.
Anyway, I love the MI example. That is the sort of thing, if taught AND practiced, that will influence the profession and its overall direction.
All that other big worded banter, to be frank, is over my head and doesn't help at all. Can't follow any of it or rethink my approach to anything having read it. (talking about MANY of the above posts, not just attacking you MSN10).
<_>
>_>
Wait. I'm not dumb. I'm smarter than all ah yall combined. I followed each and every post just fine and thats my final answer. So.................there.
I appeciate the exchange msn10 and hope I'm not coming across as snarky either.
My perception is that most people find NDs to actually HINDER communication between health care providers. If one nurse tells another nurse that this patient has impaired mobility r/t loss of limb & weakness, they'd probably have to follow it up with a translation as well as other relevant info - pt has a right BKA due to diabetes, is weak & needs assistance getting OOB. So I don't see ND assisting with communication there.
Does it help students? The concept that nurses need to consider mobility issues is important. But I think students can easily learn that concept without the awkward wording of ND. If a student can't figure out that mobility MIGHT be an issue in a pt with a BKA, then ND aren't going help, are they? And I know I'm not the only who found ND MORE confusing than helpful.
In general ND as I was taught them seem circular. The student/nurse recognizes mobility might be an issue for the BKA pt. The student/nurse does an assessment. They see that the pt is weak and unsteady. They determine that the pt should have assistance getting OOB. Where exactly does formally hanging the label of "impaired mobility" add any value?
I see that the issue of mobility directs the nurse's assessment - a young pt in for a nose job may not get such an intense mobility assessment from the nurse as an elderly BKA pt. If a patient needs assistance OOB because of BKA and weakness, tagging on the ND "impaired mobility" in no way further clarifies things.
Sorry it is off topic but when doing a ND in a community setting, there is a difference.
Primary Prevention: "Relates to activities directed at preventing a problem before it occurs (Keller et all., 2004). Dietary teaching during pregnancy, smoking prevention education, fluoride water supplementation, immunizations. Screenings such as mamo, lipid panel, lead screening exams, are secondary because you are looking for problems that are already there, not prevention.
Secondary Prevention: Any type of screening. Refers to early detection before signs and symptoms have begun and targets populations with certain risk factors. Secondary activities include Mammography, blood work, blood pressure screening, pap smear, smoking cesation, vision screening, dental exam, etc. (Keller, 2004; McEwen and Pullis, 2008).
An A1c is a screening and therefore not primary prevention for diabetes but rather diagnostic, but it is primary prevention for other diseases that can be prevented by treating diabetes, such as renal failure, neuropathy, etc.
A lipid panel is not primary prevention for hyperlipidemia, but rather secondary, but it is primary prevention for diseases that can be prevented by controlling lipid levels such as CAD.
Controlling hypertension is not primary prevention of hypertention, but is is primary prevention for diseases and conditions that could result (but are not currently present) from hypertension.
I appeciate the exchange msn10 and hope I'm not coming across as snarky either.
My perception is that most people find NDs to actually HINDER communication between health care providers. If one nurse tells another nurse that this patient has impaired mobility r/t loss of limb & weakness, they'd probably have to follow it up with a translation as well as other relevant info - pt has a right BKA due to diabetes, is weak & needs assistance getting OOB. So I don't see ND assisting with communication there.
Does it help students? The concept that nurses need to consider mobility issues is important. But I think students can easily learn that concept without the awkward wording of ND. If a student can't figure out that mobility MIGHT be an issue in a pt with a BKA, then ND aren't going help, are they? And I know I'm not the only who found ND MORE confusing than helpful.
In general ND as I was taught them seem circular. The student/nurse recognizes mobility might be an issue for the BKA pt. The student/nurse does an assessment. They see that the pt is weak and unsteady. They determine that the pt should have assistance getting OOB. Where exactly does hanging the label "impaired mobility" come into play there? I see that the issue of mobility directs the nurse's assessment - a young pt in for a nose job may not get such an intense mobility assessment from the nurse as an elderly BKA pt. If a patient needs assistance OOB because of BKA and weakness, tagging on the ND "impaired mobility" in no way further clarifies things.
Yes to this also.
If we succeed in creating our own language to communicate with other nurses with..............in the end, what have we contributed and accomplished. Outside of alienating other departments/professions.........I don't see the advantage.
Perhaps the answer lies somewhere in the middle. Maybe we don't need to hold them up as our "sacred cow" anymore but at the same time not throw the baby out with the bath water.
Wonder if the answer isn't that it simply should be left as a teaching instrument. IDK. Just making small talk about a very big issue.
msn10- question here... can you specifically identify which ND helped in this case and how it helped lead to an answer? I just reviewed a list of NANDA approved ND and I'm not seeing how NDs would help further the search for an answer.
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.
A lipid panel is not primary prevention for hyperlipidemia, but rather secondary, but it is primary prevention for diseases that can be prevented by controlling lipid levels such as CAD./QUOTE]
msn10- question here... can you specifically identify which ND helped in this case and how it helped lead to an answer? I just reviewed a list of NANDA approved ND and I'm not seeing how NDs would help further the search for an answer.
Sure.
Nausea is a ND as well as Diarrhea.
Those are 2 of the problems my daughter was having. I originally tried to treat her for the anorexia symptoms because that is what the doctor thought she had. I disagreed with him because even though she was eating less, it hurt her to eat. So if I would have used the ND "Nutritional imbalance: less than body requirements" and the care plan based on the medical dx, I would have (and did) make her symptoms worse.
So one night, I started looking through some nursing care plans for nausea and vomiting to make sure I was doing all I could to relieve her symptoms. I wasn't actually looking for the cure at this point. When I looked at a few of the care plans, it talked about doing a 'dietary holiday' as an intervention for all the nausea, vomiting and diarrhea NDs. Basically start taking foods away and start over to determine if it is a food issue. I have the care plans in a book, I would email them but I would have to re-type all of them. If you have access to the new 2011 ND's and care plans (I have them thru school) then you can see some of the interventions are updated and in one of the books I have it even talks about the prevalence of celiac relief and how nursing and dietary are the only ways to treat the disease.
That is how I discovered it. Now I am sure I will get backlash from some that I could have figured it out some other way, but it worked for me.
In general ND as I was taught them seem circular. The student/nurse recognizes mobility might be an issue for the BKA pt. The student/nurse does an assessment. They see that the pt is weak and unsteady. They determine that the pt should have assistance getting OOB. Where exactly does formally hanging the label of "impaired mobility" add any value?
I see your point, but go back to the time before you even walked into a room for the very first time. How did you know that a BKA had limited mobility? Sure, most people would understand that, but doing a ND for impaired mobility can cover a lot of things for a student. So they know that on an ortho floor, you are going to have a lot of it. Or on a cardiac floor you will have a lot of impaired tissue perfusion.
Now, they can organize their activities.
If you have someone with impaired mobility, what do you do? Describe in your assessment and plan how bad the IM is and what you are going to do about it. How are you going to tell the next nurse what the baseline was and how far the patient has come? What about the evaluation? Did your plan of care work? Did they only have IM or was their some fatigue, acute pain, or other ND's as well. Would you add more to your care plan to address those nursing issues?
One thing I learned from being an instructor is there is nothing common about common sense. Even nurses with a boatload of it can loose it when they get overwhelmed or nervous especially if they are new. Students need ways to classify and organize information.
For some, the ND isn't helpful, some like concept mapping, some just have the ability to see the big picture. But ND takes nursing down to a very basic step and I think the most confusing part of it all is the wording and trying to remember all of the NDs. So should it be revised? Yes, and the new version does a better job than last time. But when teaching nursing to new nurses, it is helpful to show them that people with the same medical diagnosis can have very different needs. And they have to assess the needs, not only the medical condition.
Okay, I have to go to bed now. This is what I get for being a school nurse and an instructor. 6 weeks off in the summer which is just too much time for me to read blogs. BTW no complaining to me that I get 6 weeks off. After 20 years of nights, weekends and holidays I am sooooo not apologizing for that.
Wishinonastar, BSN
1 Article; 1,000 Posts
Yes, they are still working towards electronic records, but they are fighting through HIPAA and it will not reduce our required documentation- it will only allow everyone to share the record. The OASIS and care plans, teaching sheets, thousands of consents, yada yada yada will still be with us until they can do something to reduce the need to protect ourselves from lawsuits. That is the only reason we do half this stuff.