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.

[klone, MSN, RN]

I don't think the OP was terminated, just reprimanded. I don't think it's necessarily fair to say she needs to take a job with fewer responsibilities. She's a new nurse, she made a mistake and hopefully she'll learn from it and become better for it. ETA: Saw I misread your post, Esme! Sorry! (and I was thinking that it was very unEsme-like!) I missed the "don't" in your first sentence! So yeah, I agree with you!

[Esme12, ASN, BSN, RN]

I don't think the OP was terminated, just reprimanded. I don't think it's necessarily fair to say she needs to take a job with fewer responsibilities. She's a new nurse, she made a mistake and hopefully she'll learn from it and become better for it. ETA: Saw I misread your post, Esme! Sorry! (and I was thinking that it was very unEsme-like!) I missed the "don't" in your first sentence! So yeah, I agree with you!

LOLOLOL...forgiven....and maybe I misunderstood I thought the OP did say she/he was fired

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.

OP we all make mistakes...learn and become the nurse you want to be.

[snmzelle]

I'm not considering NP as I don't have the resources to continue on with more schooling. Yes, they did teach Nsg dx in college and I should have refreshed on that b/f I documented. No, they didn't teach me how to chart. the nurse preceptor wasn't much of a trainer, kept saying she was too busy to teach me. But I don't blame this error on her, I should have known better. I do have a lot to learn as a new nurse, but when ever I don't know something, they criticized me for not knowing it. I did not know how to place IVs or do blood draws and they all said that I should have learned that in Nsg school, but our college didn't let us stick patients.

I was teetering on how much i should ask for help and how much I should act like I know it. In doing so I went over board on trying to show that I am capable and made a mistake. I never got encouragement or support from my preceptor and I think the stress of not getting any positive feedback caused doubt in myself and played a role leading to more errors on my part. I may have done better in a less hostile learning environment.

[judybsn]

It makes me sad that a preceptor would let a student down like this! I always did the very best I possible could with new nurses I was mentoring and prided myself in getting them a good start. Shame on your preceptor. She should not have accepted the job if she really didn't want to do it properly.

[Crazynut]

This whole situation is a hot mess. No one uses nursing dx like that. And if the facility want you to document that way. I would clock out and never come back. You have to remember that documentation is a part of the pts legal medical record. If they sue yrs down the line you may not remember the pt or the situation. So your documentation needs to be rock solid. If you make up some random nursing dx that you yourself dont even understand the lawyer will call you out on it. And make you look incompetent in court. Be very short and objective but document enough that yrs down the line you can read your documentation and understand/remember what happened. I know nurses whos good documentation saved their butt in court! And if your co worker refused to document the fall you should have documented a note and told your manager. Every pt fall is to be reported in the chart and in the employers incident report system. Sounds to me like you need to find a new job. That place sounds like a hot mess. Aint nobody got time for that! You seem like a good caring nurse. You deserve better. Keep it moving! Onward and upward! You are never too old to be who you want to be!

[sistrmoon, BSN, RN]

I don't think the OP was terminated, just reprimanded. I don't think it's necessarily fair to say she needs to take a job with fewer responsibilities. She's a new nurse, she made a mistake and hopefully she'll learn from it and become better for it. ETA: Saw I misread your post, Esme! Sorry! (and I was thinking that it was very unEsme-like!) I missed the "don't" in your first sentence! So yeah, I agree with you!

No, Esme is right. OP said she got fired for it. I can't imagine there's not more to it than this, but here's the quote: "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. "

[snmzelle]

To all of you who offered advise and support, thank you so much. I was indeed terminated. Surprisingly, I was offered 3 other positions since then and am currently employed again for the County with a higher position and higher pay believe it or not.

The Director and Nurse manager said they are rarely wrong about their intuition and felt I'd be a successful supervisor on the unit. I have to pinch myself to make sure I am not dreaming this, I felt so welcome and appreciated. I used to teach NCLEX and have demonstrated exceptional skills in my assessments and courteous/personable patient care along with a good work ethic.

I just need some practice with my charting which could have been intervened had my preceptors shown a slight interest in helping me to be successful; not to say I blame anyone, however, setting the stage for learning leads to fewer mistakes.

I am looking forward to learning from my previous mistakes and becoming the nurse I want to be. I believe I have full support at the new facility and feeling comfortable will contribute to my development.

My best to all of you, and edmia, thank you for the book reference.

mzelle

[Debilpn23]

Congratulations on your new position!!! I'm very happy for you. Like they say things happen for a reason.

[snmzelle]

thank you Debi!

[Esme12, ASN, BSN, RN]

To all of you who offered advise and support, thank you so much. I was indeed terminated. Surprisingly, I was offered 3 other positions since then and am currently employed again for the County with a higher position and higher pay believe it or not.

The Director and Nurse manager said they are rarely wrong about their intuition and felt I'd be a successful supervisor on the unit. I have to pinch myself to make sure I am not dreaming this, I felt so welcome and appreciated. I used to teach NCLEX and have demonstrated exceptional skills in my assessments and courteous/personable patient care along with a good work ethic.

I just need some practice with my charting which could have been intervened had my preceptors shown a slight interest in helping me to be successful; not to say I blame anyone, however, setting the stage for learning leads to fewer mistakes.

I am looking forward to learning from my previous mistakes and becoming the nurse I want to be. I believe I have full support at the new facility and feeling comfortable will contribute to my development.

My best to all of you, and edmia, thank you for the book reference.

mzelle

CONGRATS!!! We all make mistakes...I think it was a bit much to fire you instead of educate you.

Things happen for a reason...one door closes another opens.

Good Luck!

[nohlsson1]

I am currently waiting to be accepted into our nursing program and I love reading forums like this. This in its self is a great learning tool for those up and coming nurses. I just wanted to say thank you for sharing your experience and thank you for those that offered advice and commented. Oh, and congrats on your new position!