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.

[firstinfamily, RN]

What about "Potential for medication intolerance" anyone could have this as anyone can have an intolerance for any medication. OR "Potential for ineffective medication use" with interventions of: monitor behaviors to determine effectiveness of medication, monitor blood levels of medication to maintain therapeutic range. It could be the medication was not at the therapeutic levels to be effective and is anyone documenting the behaviors so a pattern can be established??

[JustBeachyNurse, LPN]

What about "Potential for medication intolerance" anyone could have this as anyone can have an intolerance for any medication. OR "Potential for ineffective medication use" with interventions of: monitor behaviors to determine effectiveness of medication, monitor blood levels of medication to maintain therapeutic range. It could be the medication was not at the therapeutic levels to be effective and is anyone documenting the behaviors so a pattern can be established??

Neither of those choices are nursing diagnoses both are medical. Knowledge deficit or ineffective protection are possibilities (defined above). One must use an approved NANDA-I nursing diagnosis from the available list categorized by 13 domains (health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationships, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development) not create one. The current edition is 2012-2014.

[snmzelle]

knowledge deficit is CLASSIC TEXTBOOK Nursing Dx.

[BrandonLPN, LPN]

"Patient is at risk for developing drug tolerance"......Why on earth would you chart such a statement in the first place? You don't ever chart what you think might be happening. Or what there might be a risk of.

Chart what you see. Chart what you did. Chart that the resident was medicated and was still displaying signs of agitation. Then express your concerns re:drug tolerance and possible dosage adjustments to the physician. Your charting will back you up.

[snmzelle]

the first person who answered my question made that clear. I'm a new nurse and should have brushed up on how to note b/f I wrote it considering I got fired for it as I probably deserved. It's an error that reduces other's confidence in once's ability to be a nurse and maybe it's true, maybe I'm just not cut out for a skilled position and probably should take a job with less responsibility. I hope that answers your question as to why on earth I would do such a thing.

[snmzelle]

the other thing I charted was: pt is at risk for discomfort d/t catheter leaking. Recommend further diagnostics to rule out possible other causes. Doo foo hit the fan when I wrote that one, big time. I was upset b/c her cath has been bleeding and leaking for over 4 weeks and they keep giving her pain meds and blindly troubleshooting why it may be leaking. She has spinal injury and I suspect bladder spasms. She also has feces leaking from the lady parts and I thought a fistula should be ruled out. She has a stage III wound on her lower spine that keeps getting wet from the leakage. I'm good with patients, just not with my co workers, I swear, I'm doomed. Previously, she had 3 loose stools. I told them to get a lab drawn for dehydration and they didn't. She ended up in ER for dysrhythmia d/t severe dehydration.

[VANurse2010]

Who documents such nursing dx nonsense in the chart, anyway?

[mariebailey, MSN, RN]

You'll learn to choose your battles. It sounds like you care about your patients, but you need to understand that you need a team to care for patients effectively. In other words, you are not benefiting your patient by alienating your co-workers. It's a hard lesson learned. It's frustrating when others don't share your view on what you feel is best for your patient, but you can't be rigid/think in black & white & still accomplish your goals. You will move on to other nursing jobs & improve your interpersonal skills if you try.

[JustBeachyNurse, LPN]

Risk for discomfort is not a nursing diagnosis. If you need to care plan, going forward get a copy of the current NANDA-I nursing diagnosis book written by NANDA-I all the acceptable nursing diagnoses are listed with definitions, related factors, defining characteristics (risk factors for risk for diagnoses)

now you know to chart objectively and factually without adding opinion or medical diagnoses

[snmzelle]

thank you, those are wise words. I will keep trying.

[snmzelle]

I documented the behaviors, he needed constant supervision b/c he's a huge fall risk. He fell and I documented it. My nurse manage got mad at me for that as well and the coworkers said that I can't handle him and he is just fine with them. So the next day, he fell on their shift and they too had to stay on constant supervision with him. But they refused to document the fall b/c they didn't want to admit that my assessment was accurate after they had already dismissed my notes as being off judgment to the nurse manager. So I called the doctor and she insisted it be documented, they still refused to make a fall note.

[BrandonLPN, LPN]

I documented the behaviors, he needed constant supervision b/c he's a huge fall risk. He fell and I documented it. My nurse manage got mad at me for that as well and the coworkers said that I can't handle him and he is just fine with them. So the next day, he fell on their shift and they too had to stay on constant supervision with him. But they refused to document the fall b/c they didn't want to admit that my assessment was accurate after they had already dismissed my notes as being off judgment to the nurse manager. So I called the doctor and she insisted it be documented, they still refused to make a fall note.

There's a lot I don't understand here.

How do you know he fell on their shift if you weren't there?

You're saying they're lying and covering up falls that happen on their shift, just because they don't want to admit you were right about him being a fall risk? That's a pretty bold accusation.

You called the doctor to tell her that a resident fell on a shift you weren't present for, and that no one is documenting that it happened in the first place? You're playing with fire. Again, how do you know he fell of you weren't there?