Nursing Dx

[snmzelle]

Hello all,

I have a question about a nursing note I placed in my charting and was reprimanded for it and was told that I didn't have the scope of practice to make this note b/c it is considered a Doctor's diagnoses. Can anyone tell me if the following note is a nursing dx or not?

Here goes: "Resident is at risk for developing tolerance to medication as evidenced by agitated behavior for longer periods of time after medication was administered"

I am thinking I was supposed to say, "knowledge deficit re: medication" but the patient is cognitively impaired and does not communicate so pt. has no knowledge per se.

thanks in advance for any input you can give me on this.

[JustBeachyNurse, LPN]

Hello all,

I have a question about a nursing note I placed in my charting and was reprimanded for it and was told that I didn't have the scope of practice to make this note b/c it is considered a Doctor's diagnoses. Can anyone tell me if the following note is a nursing dx or not?

Here goes: "Resident is at risk for developing tolerance to medication as evidenced by agitated behavior for longer periods of time after medication was administered"

I am thinking I was supposed to say, "knowledge deficit re: medication" but the patient is cognitively impaired and does not communicate so pt. has no knowledge per se.

thanks in advance for any input you can give me on this.

Medication tolerance or risk for is not a valid nursing diagnosis. It seems to in fact be a medical diagnosis.

Cognitive impairment status is not a contraindication to knowledge deficit; in fact it's a related factor.

Per NANDA-I "Deficient Knowledge-- absence or deficiency of cognitive information related to a specific topic. Defined by exaggerated behaviors, inaccurate follow through of instruction, inappropriate behavior (hostile, agitated, pathetic) related to cognitive limitation lack if exposure, lack of interest in learning, etc.

Or

Ineffective protection ( decrease in ability to guard self from internal or external threats such as illness or injury) AEB restlessness & maladaptive stress response (agitated behaviors) related to pharmaceutical agents?

[snmzelle]

thank you, that helps a lot.

[Esme12, ASN, BSN, RN]

why are you documenting this is the chart?

[snmzelle]

why are you documenting this in a chart?? or this IS a chart? I don't understand your question, but did get an answer to mine above, so I'm all set, thanks!

[Here.I.Stand, BSN, RN]

Risk for developing tolerance isn't a nursing dx. I'm also wondering why you go to "the pt is becoming tolerant," vs. "this med is not effectively controlling pain/anxiety/etc."

[OCNRN63, RN]

I don't understand how this could be perceived as "tolerance" if the pt. is "agitated for longer periods of time after medication was administered." Maybe I'm dense, but the way that sounds to me, the patient sounds under medicated.

[Esme12, ASN, BSN, RN]

why are you documenting this in a chart?? or this IS a chart? I don't understand your question, but did get an answer to mine above, so I'm all set, thanks!

Excuse my typo...IN the chart. I am always curious and wanting to learn how things are done in other places...it is an odd format for patient charting/physician communication. Is this a new format or a format your facility uses?

[snmzelle]

Hi, I'm an RN and made an error in my nsg dx which is not in my scope of practice. We have electronic charting/nursing notes. When I sneeze, I have to document that I sneezed in 10 different programs on the elec. sys and 5 or 6 in the hard copies and then fax several copies to each dept and then put some more copies in the "to scan" folder, get the key and write my initials in the med room another 100 times and never forget to put my initialed tissue in the black bin, not the red one. lol!

[ICURN3020]

Alrighty then.....

[PulselessNine]

OP - I imagine you started the thread because someone told you that you overstepped your bounds with your chart entry. If you correct every little typo in the same manner as you have in this thread you can expect your supervisors and coworkers to be hyper vigilant for the opportunity to correct you. They may even allow you to embarrass yourself when they could have otherwise helped you out. You can be always right and alienate those around you or you can step back and observe your limitations and watch the helping hands come from all directions. Have a great day.

[ICURN3020]

OP - I imagine you started the thread because someone told you that you overstepped your bounds with your chart entry. If you correct every little typo in the same manner as you have in this thread you can expect your supervisors and coworkers to be hyper vigilant for the opportunity to correct you. They may even allow you to embarrass yourself when they could have otherwise helped you out. You can be always right and alienate those around you or you can step back and observe your limitations and watch the helping hands come from all directions. Have a great day.

I was thinking the same.....well said!