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.
You nailed the whole issue right on point. KUDOS to you!!
Not inferior or separate, but rather an integral part of the team.
I find that most often students understand the nursing process and waste lots of time in a dither over whether or not this vague NANDA dx or that one is correct, and lacking the big picture at that point, are often filled with anxiety about getting a failing grade if they doin't pick the right one.
It adds an extra layer into the care-plan process that seems to me more akin to driving to your destination through a muddy or slushy road, and there is an abundance of nursing history and theory about "who we are and what we do" before and after the NANDA implementation I recall very clearly in it's incipient stages back in the early eighties.
I find lots of people aren't aware that nursing care plans existed before NANDA and since nursing education itself is those interventions and implementations that reflect where we are so far, the addition of a nursing dx that no other discipline understands is very counterproductve. As I've bored people to death with here many times :) our careplans were dynamic, easily accessable and understandable, and could be contributed to by a CNA in some areas he or she would normally be more involved in than would the LPN or RN.
This hospital clearly recognized nursing as a stand alone profession, because the Progress Notes contained notes from the doctors, nurses, CSWs etc on the same page. We used an abbreviated SOAP note format - and for routine notes all concerned would address a problem from the care plan/MD dx the professional judged to be of priority for that shift.
This approach worked well because it meant a greater cohesion (translated meant the doc had a note in his or her face so more likely to read it). The NANDA system made this process obsolete - and took a large chunk of valuable information that could be gleaned from our input into a murky realm most people either laugh at or ignore.
In any other discipline an unworkable idea is promptly jettisoned and/or revamped, but this seems to me almost a sentimental attachment to, because it's original goals were and still are laudable. I can't mock too much because I remember the excitement and fanfare reflected in my nursing journals of the day.
What insurance company do you know of who even knows what the hell a nursing dx is - let alone be satisfied that it has enough clarity to assign a cash value to? It amounts to a foreign language to them.
Since an overwhelming percentage of providers do not use NANDA for that reason, I am satisfied they know we are doing those things we went to a school to learn and are licensed to do. Requirements for documentation have increased, not decreased, the goal to qualify our roles in greater detail.
That is not true at all, and unfairly slashes the broad brush across the medical community as a bunch of robot borgs when there are hundreds of thousands of docs who" treat the person". Since almost nobody uses them, does that mean nobody is treating "the whole person"?
I work in home health and have never seen a nursing dx anywhere. Our recerts have nursing goals just as in the olden days without a NANDA dx in sight. If I were a doctor I wouldn't want to sign something that had a lot of incomprehensible terminology either.
All NANDA did was assign new verbiage with a distinctly 70s new-agey flair. Most nurses who actually provide the care at the bedside don't use them, they are used in LTCs - but does the rank-and-file see/use the nursing dx? Care plans never making it past the office door aren't being used, whereas the care-plans pre-NANDA were at arms length to anyone interacting with that patient.
The treating the whole patient process is done at the macro level in acute care with from OT, PT, social workers, dieticians etc and the maestro of the whole thing in theory would be a PCP as the hub of the wheel. The development of a specialty residency in Family Practice was done for exactly that reason - as very few docs stop at the GP level anymore.
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 say you? i have to disagree.
two comments here:
1. however obvious the symptoms leading to a conclusion are: we are not authorized as nurses to diagnose a disease. period, end all discussions now. you do not get to do this! want to diagnose? go and get m.d. written after your name. or go to bat for 30 years and get doctors to allow you to do this. or, wait, they already do. it's called having a license as an np.
2. the "nursing diagnosis" of pnemonia (or any condition) is not a wasted exercise. nd is pretty much a nursing student exercise. in itself, it can be very helpful in breaking down and analyzing a health problem; looking at the pathophysiology behind a problem and and focusing a student nurse in planning and evaluating care. it is a training exercise, and it helps in critical thinking. don't throw the baby out with the bath water!
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
however obvious the symptoms leading to a conclusion are: we are not authorized as nurses to diagnose a disease. period, end all discussions now. you do not get to do this! want to diagnose? go and get m.d. written after your name. or go to bat for 30 years and get doctors to allow you to do this. or, wait, they already do. it's called having a license as an np.
*** um, we don't need to do the actual diagnosing in order to use the medical diagnosis. nearly _all_ of my patients already have a medical diagnosis. every single member of the health care team except nursing already uses it.
that nursing feels the need to come up with our own, silly, diagnosis is evidence of our own low self esteem.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
99% agree... and here goes that 1%
(the following is not based on description or summary of any real patient - for HIPPAA's sake):
There is a middle-aged female patient with h/o chronic migraines and chronic low back pain. Physician's Dx in ER: low abdominal pain. Tests' results ruled out surgical pathology, so she is under observation and treated for mild dehydration (medical dx#1), constipation (medical dx#2) and chronic pain (medical dx#3). Home meds to be continued while on floor: oxyContin for back pain and vicodin PRN. She is unemployed, poor, uneducated, has no primary care doctor and only comes to ER to get her "pain pills" every couple of weeks or so. She is cooperative, not very complaining but somewhat anxious and concerned about her own health and her ability to support her 5 small children.
There is a sad medical joke saying: "being stupid or poor isn't a diagnosis yet". There is really no useful medical diagnosis to describe what's going on with this patient as a whole person ("major depression" might be the closest thing to use, but it may very well not be the correct one). I can imagine that most probably the patient will be prescribed "some" Xanax to "control her anxiety", more of her "pain pills" and something for constipation, told to drink more water and eat more fruits and veggies. Therefore, each of her single medical problems will be properly "addressed" and she is discharged to whence she came from. It is very difficult for a doctor even to address her obviously forming dependency on opioids, b/o she truly has that head and back pains and therefore can be sent to pain clinic consult but hardly anywhere else.
Why such a patient cannot "officially" be given diagnosis of "health maintenance, ineffective, r/t lack of material resources, ineffective individual coping, etc"? At least, that would give a picture of an individual unable to manage her own health issues, and in need of much more help than giving her another prescription. Yes, it is a "nursing diagnosis" according to NANDA, but if it encompasses problems crying to be addressed and vitally important for the health of this patient, does it really matter? :redbeathe:redbeathe:redbeathe
Sorry for the long rant...
I agree with you if the patient was actually admitted for mild dehydration, constipation and chronic pain but still --or any type of "social admit" sure to bring heaps of burning coals onto the admitting physician - the problem with that patient is not so much a nursing dx vs medical dx thing as it is an inappropriate use of the Emergency Dept, and you could probably tattoo "follow up w/ PCP on Monday" on their hand and . . . the staff of the ED will sometimes make the appt for them or otherwise hook them up with a PCP or a list of no cost/low cost clinics.
If they don't have a primary care provider it isn't for lack of trying by the beleaguered ER staff in most cases. There is just a large population of people who show up for tx of flares of chronic illness and don't maintain a regular schedule of office visits with the primary care provider as they should, where all of those pieces of the puzzle are supposed to be put together.
If the doctors used the more descriptive nursing dx of "ineffective coping" etc they still have to come up with a plan to treat it - and the plan to treat it even if you do call it a diagnosis and assign a code for billing purposes doesn't offer more options (that I can think of anyway) than would if a medical dx was used.
There are lots of doctors who love to treat the whole patient and/or that patient's entire family(and may secretly agree a patient has a Disturbed Energy Field) just as there are those who love looking at slides or x-rays or doing surgeries all day long. They like the "holistic" concept if you will and they enjoy treating grandma's CHF and doing well-baby checks. They attend graduations and funerals. They don't make a ton of money, either. I just feel like having worked with so many people over the years who are "treating the whole patient", "are concerned with the patient's reaction to the disease" "are patient advocates" etc.
If you strip the wording of the weirdness imparted by the nursing dx you have some very basic and universal concepts that are in no way the exclusive purview of nurses. If your doctor asks "how are you doing today?" because he knows you just found out your biopsy didn't look so good, he or she is concerned with your reaction to your illness. If he says "let me give old Joe a call and see if we can't get you in to see him a little sooner" he or she is being a patient advocate and all this constantly attempting to define ourselves against any other discipline as a foil is unworkable and . . it's silly to have actual turf wars wherein we must drop a pebble on one side or the other and . I went on a rant as well!!!
I'm not even going to pretend like I use nursing diagnoses in my practice, because I don't. I haven't even thought about them since school, to be honest. I also definitely think that when you look at the lists in books, they can get into the realm of the stupid sometimes.
However, I actually do think they are useful to students (even though I feel like I'm going to be hit by some tomatoes for saying so.) I think they are helpful in teaching the student how to think like a nurse. If your diagnosis is pneumonia, the only way you can really fix that is through medical intervention, and the nurse does the very important job of implementing the medical treatment plan. However, if the problems are stated as impaired gas exchange or ineffective airway clearance or anxiety or whatever, it requires the student to think: What can I do as a nurse to fix this problem? It encourages the student to produce independent nursing actions.
I don't see how going from specific information and standard nursing interventions to vague descriptions helps someone to "think like a nurse" when there is already a diagnosis made by the physician or why it would be a good idea to produce independent nursing actions based on something called "impaired gas exchange". If all you knew was that how could you produce independent nursing actions and what might they be? How would it change evidence-based interventions derived from the diagnosis that we would already either be doing or know of a recognized intervention for that specific dx that is not part of the care plan and suggest that it could or should be? Without a specific dx how could you do that?
Not trying to annoy - it's just that you could probably fill several pages with nursing diagnosis lingo and in reality not say a blessed thing. It's even happened in this thread!
however obvious the symptoms leading to a conclusion are: we are not authorized as nurses to diagnose a disease. period, end all discussions now. you do not get to do this! want to diagnose? go and get m.d. written after your name. or go to bat for 30 years and get doctors to allow you to do this. or, wait, they already do. it's called having a license as an np.
*** um, we don't need to do the actual diagnosing in order to use the medical diagnosis. nearly _all_ of my patients already have a medical diagnosis. every single member of the health care team except nursing already uses it.
that nursing feels the need to come up with our own, silly, diagnosis is evidence of our own low self esteem.
oh, come now, nurses accept and use the medical diagnosis 24/7 to plan and evaluate care. to claim otherwise is silly.
we are not talking about using the diagnosis, we are talking about dissecting the diagnosis. "pneumonia" is a word with associations attached to it. a nursing student needs to understand the attachments, and formulate
actions based on the physiological changes. this is not about knowing the definition of pneumonia; it's about
breaking down the s/s and implications for a new nursing student, and them understanding why the diagnosis is what it is.
that said, if you have a pt. with decreased breath sounds, an x-ray that shows consolidation, and a pt. coughing up purulent sputum; you know, i know and everybody else knows the pt. has pneumonia.
tough. you don't get to utter the word until the md says so. yeah, it's not always effective, but it is not going to change.
I don't see how going from specific information and standard nursing interventions to vague descriptions helps someone to "think like a nurse" when there is already a diagnosis made by the physician or why it would be a good idea to produce independent nursing actions based on something called "impaired gas exchange". If all you knew was that how could you produce independent nursing actions and what might they be? How would it change evidence-based interventions derived from the diagnosis that we would already either be doing or know of a recognized intervention for that specific dx that is not part of the care plan and suggest that it could or should be? Without a specific dx how could you do that?
Because not every pneumonia pt. can benefit from "standard nursing interventions". Try getting a CP pt. to use an IS. "Standard", but not really helpful to this pt. You HAVE to be able to think critically, and not rely on the cookbook standards. SO many nurses do NOT have this ability. Hence, nursing diagnosis.
Not trying to annoy - it's just that you could probably fill several pages with nursing diagnosis lingo and in reality not say a blessed thing. It's even happened in this thread!
I don't see how going from specific information and standard nursing interventions to vague descriptions helps someone to "think like a nurse" when there is already a diagnosis made by the physician or why it would be a good idea to produce independent nursing actions based on something called "impaired gas exchange". If all you knew was that how could you produce independent nursing actions and what might they be? How would it change evidence-based interventions derived from the diagnosis that we would already either be doing or know of a recognized intervention for that specific dx that is not part of the care plan and suggest that it could or should be? Without a specific dx how could you do that?
Not trying to annoy - it's just that you could probably fill several pages with nursing diagnosis lingo and in reality not say a blessed thing. It's even happened in this thread!
To further your point about turf wars, I'll add, you can probably fill several pages with ND and not say anything everyone else isn't already doing............without all the dressing up of it.
The old sand in the line separating us from medical theory is flawed: "The medical theory treats diagnosis, nursing is concerned with the patient's reaction to illness."
Well.............ok. According to that description, if I call an MD and say my patient is SOB, they will follow by asking me the DX. If said DX were Pneumonia, and the definition of medical vs. nursing theory were true, they'd simply order antibiotics and be done for the day. I'd be the one suggesting oxygen, breathing treatments, PT/OT prior to D/C.................because, according to our sand in the line discussed above, as the nurse, I'm the only one who is trained to think that way.
That is never how it has gone for me though. Being aware of and anticipating the "reaction to disease" is not unique to nursing nor is it something that needs redefined by special descriptions outside of the medical diagnosis.
The PT dept. has it's primary focus of improving my post hip surgery patient's gait..............but they doesn't stop them from realizing they patient can no longer go bowling and will suffer socially. They too can contact Social Services if they deem this a problem that needs addressed (perhaps with family) just like us nurses can.
If someone were to ask me, I'd say ND have lost their use because they make assumptions. I already pointed out one above (that medical theory does not address the reaction to illness). Another assumption it makes is that nurses are working all alone, running into patients with no other members of the care team able to be found or contacted.
Nurses can't diagnose. Allrighty then..........but how many nurses are truly dealing with a patient who does not already have a diagnosis anyway? ER Nurses, more specifically the triage nurse maybe.......but there is an ER doctor on site. Home Care Nurses maybe, if the patient displays new onset symptoms, but in this case we can get ahold of a doctor via phone and/or send the pt. to the ER.
So, the ND assumes we are treating a patient, no diagnosis in place, and must act alone completely and move forward without any medical diagnosis being obtained. This situation is rare indeed, and if it were to occur, I can assure you, moving towards obtaining said medical dx is more helpful than using ND.
Maybe back in the stone age, before telephones/cars/computers ND had its place. Then, perhaps a nurse would find themselves trapped with a patient with no other resources at hand. These days, it just doesn't happen enough to justify the continued use of ND. Give up the foolish and poorly thought out line in the sand our leaders have created for us and join the team.
Specializes in Infectious Disease, Neuro, Research.
We are not talking about USING the diagnosis, we are talking about dissecting the diagnosis. "Pneumonia" is a word with associations attached to it. A nursing student needs to understand the attachments, and formulate
actions based on the physiological changes. This is NOT about knowing the definition of pneumonia; it's about
breaking down the s/s and implications for a new nursing student, and them understanding WHY the diagnosis is what it is.
That said, if you have a pt. with decreased breath sounds, an x-ray that shows consolidation, and a pt. coughing up purulent sputum; you know, I know and EVERYBODY else knows the pt. has pneumonia.
Tough. You don't get to utter the word until the MD says so. Yeah, it's not always effective, but it is NOT going to change.
I'll disagree with you on that. I had 20 years of direct care before I went for my RN, and "Nursing Diagnoses" are the most convoluted, dissociated, disjointed clap-trap taught, discounting an "Astral Projection" class I saw offered. My cohorts, with experience ranging from nil to 5 years as an oral surgeon's assistant had the same difficulties. Nursing DXs do not connect porcesses, unless your individual learning method is verbally relational and non-exclusionary. The problem with the Nursing DX is that it assumes utter lack of knowledge or insight. It is a statement of the obvious. 99.9% of the time we will have a working medical DX (from the MD), and the issue is our ability to effectively support our reasons for intervention/tx for the purposes of reimbursement. If we have a DX, we should have established care-pathways.
Because there was a push to have "mid-level" care management in the Age of the Golden MD (50s-70s), nursing needed a mechanism whereby intervention(s) could be initiated without disturbing the Holy Doctor. At the current time, we no longer need this buffer model, and if we are in an emergent situation with a total absence of MD direction, guess what- it is emergent. We don't need the MD. We respond with our highest level of training & certification. Maybe time to get that Wilderness Medic or TacMedic patch, eh?
As far as, "yeah, its not always effective...", it had better be working towards being effective, particularly with outcome based reimbursement mandates.
I do not advocate nurses "making the diagnosis", I do advocate doing away with a marginalized, antequated system that retards effective use of time and resources.
the staff of the ED will sometimes make the appt for them or otherwise hook them up with a PCP or a list of no cost/low cost clinics. 
I went on a rant as well!!! 
Frozen08
23 Posts
You nailed the whole issue right on point. KUDOS to you!!
Not inferior or separate, but rather an integral part of the team.