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.

[SionainnRN]

Where do you work? I haven't done nursing dx since nursing school and I'm just curious what units or facilities have you chart using them.

[MunoRN, RN]

I think wording your assessment in the form of a nursing diagnosis probably didn't help and may have confused what you were trying to say, which then contributed the initial criticism from your supervisor. Is the expectation that you use ND terminology in your assessments and care planning? At every facility I've ever worked at, the use of nursing diagnosis terminology is specifically forbidden.

[RescueNinjaKy]

I would file an incidence report, just documenting in the chart that the patient fell doesn't seem to be enough. And honestly I wouldn't give a hoot to what the other nurses say, you can refuse to document it all you want, but I'm gonna want to document and file an incidence report if patient safety is being compromised, gotta protect that license

[jadelpn, LPN, EMT-B]

There's advocating, then there is stating that things are to be done that is not within a nurse's scope to do. (ie: labs NEED to be drawn)

It DOES sound like this patient was a hot mess and if no one was responding to your assessment of what was going on, then in fact you have a few other alternatives (omsbudman, for instance).

You could also contact the state regarding this--in fact if residents are falling right and left, there's pressure sores.....I get that you were horrified by the treatment given to the residents. I think it is perhaps a good thing that you are no longer working there, as do you really want to be involved in less than stellar care--and when advocating--and granted, you crossed a boundry into medical diagnosis and treatment--being fired for it?

The squeaky wheel may get the grease, but it also gets canned pretty quickly in facilities that care more for dollars and have little sense.

Going forward--have you thought about case management? Going on to become and NP or legal nurse consultant? Even a PA? That puts into play the way you come across as your thought processes. Which is a good thing, but just not as a nurse in skilled/LTC (or even acute care for that matter).

Best wishes going forward.

[snmzelle]

I was there when he fell, I say his shift b/c they had me doing cares. To clarify, was my shift as well, but even though I am a BSN,RN, I was doing cares while he was charge nurse. I was walking out of the break room and saw the fall. I should have made a nursing note, but he did lie, he said he would call the doctor and he didn't. He refused to document the fall b/c when he fell the day previously while I was charge, he told the nursing manager that he doesn't fall when he's in charge and that I just can't handle the patient.

[snmzelle]

this is my first nursing job, I didn't realize that nursing dx is not really used until you just told me. No, msg dx is not the expectation. I should have followed the same pattern as the other nursing notes. I agree that I deserve discipline for the notes I wrote, but I don't believe that patient falls should be ignored so as not to have too many fall reports on record. If an incident report were filed every time this pt fell, another type of fall precaution could be assessed, one more successful, thus being more safe for the pt.

[snmzelle]

that was the attitude I adopted. I filed an incident report when he fell while I was charge and I was reprimanded for it by my nursing manager. She said that it really wasn't a fall, he just slid off his chair. According to CMS, when a pt. slips off chair, voluntarily or involuntarily, that is a fall.

[klone, MSN, RN]

No, nursing dx are not used in real life.

The stuff you wrote in the chart about "med tolerance" and differential dxes regarding the foley catheter - those are not things you would write in the chart - those are concerns you would communicate directly with the physician. Charting is for assessments, where you write what you observed, and what you did.

[snmzelle]

Hi Jadelpn,

I am in my late 50's, this was a career change for me. I used to work in medical administration and was going to nursing school during that time. I got a late start so going on to NP or legal nurse is something I would love to do, I'm sort of out of time. I'm a federal employee for the VA and have learned that the nursing manager, her boss, her boss's boss, HR, the medical director and even the union all back each other up. They have known each other for many years and will certainly not be listening to a new nurse, and outsider who has only been there 3 months.

Thank you !

[snmzelle]

Yes, I realize that now, a little too late, but it is a lesson learned. thank you.

[Esme12, ASN, BSN, RN]

this is my first nursing job, I didn't realize that nursing dx is not really used until you just told me. No, nsg dx is not the expectation. I should have followed the same pattern as the other nursing notes. I agree that I deserve discipline for the notes I wrote, but I don't believe that patient falls should be ignored so as not to have too many fall reports on record. If an incident report were filed every time this pt fell, another type of fall precaution could be assessed, one more successful, thus being more safe for the pt.

Did nursing school not go over charting with you? In orientation for your job did they not go over what kind of charting they prefer to be used?

That is what I didn't understand with your post...you don't document in nursing diagnoses lingo. Nursing diagnosis belong on the care plan.

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.

That is why I was asking why on earth were you charting in nursing diagnosis format. It doesn't belong in the "narrative charting".

It might not be the charting itself that got you terminated but an apparent unwillingness to learn and grow as a new nurse by being argumentative and unwilling to adhere to policies.

I don't think you should use this as a sign that you don't belong in "skilled care" and should take a job "with less responsibilities" as nursing is riddled with responsibilities. Especially if you are considering an advanced degree that will come with even more responsibilities. I think you should view this as a learnig expereince and understand as a new nurse you have a lot to learn and open your mid to the fact that those with more experience can teach you what you need.

No...a fall should never be ignore however you can learn how to change your approach so you are not interpreted as abrasive or argumentative.

[edmia, BSN, RN]

This book helped me tremendously during my first months as an RN. There might be a newer edition now. I kept it in my locker for quick reference.