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.
Specializes in Infectious Disease, Neuro, Research.
Really ??????????
What if you don't agree with the Medical diagnosis? Many of you are basically saying docs don't make mistakes.
With a nursing diagnosis, you are able to do interventions on your own regardless of the correct or incorrect medical diagnosis.
Do you really want to depend on the doc for your intervention? You can definitely consider his or her opinion, but I have just as many stories from my years in practice about docs being wrong and nurses figuring out the problem based on their experiences. Treating patients on your own may produce positive results to a non diagnosed problem. Yes, the ND process is long and should be revamped, but...
be careful about giving up our practice to docs who make a diagnosis on a patient they may spend no more than 10 minutes assessing.
You kinda lost me there. What assessment do I make that I am unable to make immediate intervention w/o a doctor, regardless of medical dx? EDIT: w/in scope of practice. We're talking emergent vs. maintenance care, and maintenance care requires orders, i.e., the MD.
Family/social needs- request a consult or validate teaching based on assessment. Physical need- either it is emergent and you do what needs doing to stabilize, or you page the doc on call.
Again, the issue is billing. Do away with the time consuming NDX, and push for legislation to allow billing pursuant to assessment findings r/medDX, or "developmental needs"- i.e., make Maslow/Erickson our billing model, since it would be hard to argue assessments based on a universally accepted, peer review validated framework, vs. the NANDA model which is both grossly inadequate/vague and overly specific.
.... 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.
I can see why you're frustrated! Thankfully that's not at all the rationale they give for nursing diagnoses in the program I'm in right now. They've told us pretty much from the beginning that we won't ever actually use nursing diagnoses in clinical practice, but that they are a useful tool for students to learn how to think like nurses when assessing patients and developing interventions. They essentially said they expect us to internalize the process, but that we're never going to have to write out a nursing diagnosis for any of our patients, or discuss our nursing diagnosis with our colleagues. While writing out OPTs based on the NANDA manual have been a HUGE headache during my clinical rotations, I've found that it has been beneficial in helping me develop good nursing judgement- however I don't expect to even utter the words "nursing diagnosis" once I enter a clinical setting.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Really ??????????
What if you don't agree with the Medical diagnosis? Many of you are basically saying docs don't make mistakes. quote]
*** We all know everybody makes mistakes. If I think the physician has made an incorrect diagnosis I will ask (insist if I have to) on an explanation as to why their Dx is the correct one. Either s/he is right and I learn something, or they are still wrong, acting as my patients advocate, I will call their boss. In my hospital that usually means a senior resident. I will ask (insist if necessary) that they come and examine the patient. If that fails I will call the staff, or even the chief of staff and explain the situation providing my assessment findings and my rational as to why I think the intern/resident/attending is incorrect.
I had to do exactly that one night when a trauma patient came in nearly frozen to death. While we were re-warming him I noticed his left foot was not warming up like the rest of him and was unable to palpate or dopple a pulse in the left (initially there were no detectable pulses in any extremity). I suspected DVT and the intern disagreed, so did the senior resident. Finally I called the attending who came in wearing his lab coat over his PJs at 0300 and before I knew it I had orders for a heparin gtt and there was a vascular surgeon at the bedside. I got a "nice catch" from the attending. I thought it was no big deal as anyone could tell the left was colder and pulse less. Just an RN doing our standard job of assessing our patients and being their advocate.
again, the issue is billing. do away with the time consuming ndx, and push for legislation to allow billing pursuant to assessment findings r/meddx, or "developmental needs"- i.e., make maslow/erickson our billing model, since it would be hard to argue assessments based on a universally accepted, peer review validated framework, vs. the nanda model which is both grossly inadequate/vague and overly specific.
please explain to me why/how nursing dx has anything to do with billing? i may be wrong but, in my computerized charting i state bp 80/40 and put pt in trendelenberg, i don't believe that a charge is generated for that nursing intervention, let alone it be billed under a nd.
as far as i have been able to discern is that the only place that they are used is in ns.
question to the professors/instructors/deans: do state boards require that nanda / nd be taught? accrediting bodies?
if so, it seems like a self-perpetuating problem i.e. there is a nursing power base that insist that nanda is the way to the promised land and they will not give it up for fear of losing that power.
WOW! Well said and I couldn't agree with you more. I've always marveled at the fact that nurses pretty much run the course of the hospital stay for the patient, and here we can't be trusted to treat a 'medical diagnosis'. I believe a nursing diagnosis helps to understand the causative factor and related etiologies, etc; but really, like you said, isn't pneumonia what we are treating?
I agree this part of nursing needs to be looked at and seriously considered for tossing out. I have never seen it in use on a medical floor. Have you?
AS a nurse for 17 years and and ER nurse for the past 10 year, Nursing DX, are a total waste of time, A triage nurse uses experience as only puts down the symptoms the patient arrives with and also what the patient states. Depending on what the severity this the nurse the patient is give to in the ER makes certain judgments as to what should be ordered even before the ER physician sees the pt ie. start a line draw blood place the pt on O2 and if the pt has a fever the triage nurse may have already given Tylenol. also if the pt comfortable with no breathing problems or acute symptoms greet the patient and ask quest as appropriate and preform a complete Physical or social assessment. If a pt shows up with chest pain or we suspect a cva you can bet your bottom dollar I going to start treatment prior to the Doctors arrival.
I have had to many failure to thrive walk up to me lately. Who in there right mind would problems with gas exchange when a person is have an asthma attack
Good grief, why are we so angry? NP's are just about the only nurses who get to bill. You are a small population and you can diagnose, and you can in some states write prescriptions and you can write orders, but you also have to consult with MD's about our diagnosis and treatment, and you must refer to further treatment. Nursing diagnosis paints a picture of a patient with a broad brush. Ex) admitting diagnosis: Abdominal pain. What as a nurse are you going to do with that? Assess, interview, and call the doctor for orders. You can't do an order for lab work, you can't do an order for an ultrasound or x-ray. All you can do is take vitals, wait for orders and comfort and educate on the present surroundings and check your patient ID and other Joint Commission guidelines. What would your nursing diagnosis be? Face it there are some things (especially in hospital type settings) that as a nurse you can't do much about unless there are care paths to start the care of the patient rolling without a doctor/PA/NP order. If I have a patient with obstructive pulmonary disease-for whatever reason, COPD, Asthma, Pneumonia-My job as a nurse is not just to observe a patient struggling to breathe and reporting like a helpless idiot, my job is to follow interventions and work with doctors/PA's and NP's etc, to address the immediate needs of the patient. However you want to document that NANDA, PANDA whatever, then figure it out. I'm going to take care of my patient. Let the Ivory Tower people determine how to say it. If I was one of those people in the Ivory Tower (IT) get it???? I would make it as simple as possible to justify the rationale for what I, the bedside nurse is doing. Home Health included. If it's out of your realm of knowing what to do, there should be a emergency (rapid) response team who does know what to do in a moments notice. I'm really tired and bored and irritated with us. We just can't seem to have a patient and understanding conversation anymore.
Oh and I do think that just because we learned something and got a degree and suffered through a 50 page report etc, it doesn't mean that things don't need to be shaken up and stirred a bit. We don't get respect as a profession writing a bunch of fluff and speaking in such language that is like legalese. It's poetic, wordy, and hypnotizing, but can probably be honed down to 3 words. You need an interpreter to understanding the purpose in the prose. It is disrespectful to me as a nurse of over 33 years to think that we can't talk plainly to one another and get to the heart of the matter. And I mean that in the most respectful way. I know theorists and other administrators and academia think about these things all the time. What they don't always take into account is the rapid care and limited staffing we have to treat and care for patients. The patient is discharged from the hospital/facility before the paperwork is completed. We need to think about things a bit more carefully and include the patient care practitioner in the decision making so that things make more sense. You'd be surprised what innovative ideas you would find.
Rob72, ASN, RN
685 Posts
You kinda lost me there. What assessment do I make that I am unable to make immediate intervention w/o a doctor, regardless of medical dx? EDIT: w/in scope of practice. We're talking emergent vs. maintenance care, and maintenance care requires orders, i.e., the MD.
Family/social needs- request a consult or validate teaching based on assessment. Physical need- either it is emergent and you do what needs doing to stabilize, or you page the doc on call.
Again, the issue is billing. Do away with the time consuming NDX, and push for legislation to allow billing pursuant to assessment findings r/medDX, or "developmental needs"- i.e., make Maslow/Erickson our billing model, since it would be hard to argue assessments based on a universally accepted, peer review validated framework, vs. the NANDA model which is both grossly inadequate/vague and overly specific.