Primary v.s. Secondary Diagnosis?

[livelovenursing]

I am having a difficult time deciphering between the primary v.s. the secondary diagnosis. The case study says that the patient is in the hospital "status post lung transplant secondary to pulmonary fibrosis." Is the primary diagnosis the fact that they are lung transplanted, or is it the pulmonary fibrosis? If someone could please explain to me as I am a bit confused. Thanks in advance!

[Natasha A., CNA, LVN]

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[Guest856929]

On 11/19/2020 at 8:36 PM, livelovenursing said:

I am having a difficult time deciphering between the primary v.s. the secondary diagnosis. The case study says that the patient is in the hospital "status post lung transplant secondary to pulmonary fibrosis." Is the primary diagnosis the fact that they are lung transplanted, or is it the pulmonary fibrosis? If someone could please explain to me as I am a bit confused. Thanks in advance!

It's a play on words that I think confused you. It appears to be a case of which came first, the chicken or the egg, but it is not. If I say that someone is septic secondary to MRSA infection, you have to ask yourself which diagnosis preceded the other. The precedent is the primary diagnosis. I will not answer your particular question, but I think you can use deductive reasoning to reach a reasonable answer. 

[ThursdayNight, CNA]

1. What's the reason the patient was/is admitted?

2. What's the preexisting condition that came/come with the patient but not the reason to be admitted?

Recheck your case.

[LubbDubb77, BSN, RN]

Primary dx - the problem you are focused on. Secondary dx - what it is caused by. 

Ex.

Primary: Ineffective airway clearance

r/t increased airway secretions (symptom, what the pt is experiencing)

Secondary: Pneumonia 

I would get a NANDA nursing dx book/care plan book. I had one when in school and they help connect the dots.

[Hannahbanana, BSN, MSN]

On 2/8/2021 at 8:29 PM, LubbDubb77 said:

Primary dx - the problem you are focused on. Secondary dx - what it is caused by. 

Ex.

Primary: Ineffective airway clearance

r/t increased airway secretions (symptom, what the pt is experiencing)

Secondary: Pneumonia 

I would get a NANDA nursing dx book/care plan book. I had one when in school and they help connect the dots.

Are you looking at your nursing diagnoses to develop a nursing plan of care? My major complaint about "care planning handbooks" is that they are indexed entirely by MEDICAL diagnoses. This makes students (and some nurses) assume that nursing diagnosis is always related to/caused by a medical diagnosis, and it's often not at all. You're in nursing school to learn to think like a nurse, not a medical appendage.

So.

Make sure you're clear on the difference between your nursing diagnosis [(ineffective airway clearance) and its related (causative) factors (look at the list in the NANDA-I to see which fit your assessment)] and a medical diagnosis (pneumonia).

If somebody has confused the picture for you by saying "(nursing diagnosis) secondary to (meaning "because of" or "due to") (medical diagnosis)" then you would find that medical diagnosis, if appropriate, in the related/causative factors list or the associated conditions list for the nursing diagnosis, which are largely but not all medical diagnoses.

[Hannahbanana, BSN, MSN]

On 11/22/2020 at 8:01 PM, cynical-RN said:

The case study says that the patient is in the hospital "status post lung transplant secondary to pulmonary fibrosis." Is the primary diagnosis the fact that they are lung transplanted, or is it the pulmonary fibrosis?

 

[Guest856929]

3 hours ago, Hannahbanana said:

 

Since it has been a long time since this was posted, lets talk about it. I answered the question from a provider's perspective. I don't know if the OP is in undergrad nursing or in grad school. I assume it is the latter. As such, the primary diagnosis is undoubtedly pulmonary fibrosis. It preceded the lung transplant and any subsequent complications from the procedure.

Operative word here is secondary which is a double entendre. It can denote something that is #2 or after the precedent, or also mean 'caused by' as you noted. If the OP is in undergrad, then they need to look at NANDA (which I thoroughly abhorred albeit being important).

Nonetheless, neither lung transplant nor PNA is a nursing diagnosis and that's part of the reason I thought OP was in grad school. I think the use of the word "secondary" confused OP. 

[neuron]

On 2/8/2021 at 7:29 PM, LubbDubb77 said:

Primary dx - the problem you are focused on. Secondary dx - what it is caused by. 

Ex.

Primary: Ineffective airway clearance

This being used as a diagnosis, admitting or primary, I'm not sure it would even be considered as an acceptable diagnosis IRL. Pneumonia or CF sure, but all these other nursing handbook diagnosis, I've never seen them being used or acceptable for an admitting or primary diagnosis, they would be flagged as unbillable or 'not acceptable'. 

I guess dx's like impaired skin integrity and ineffective airway clearance is what nursing school is focused on. 

 

[Hannahbanana, BSN, MSN]

Two concepts here. As this is a student question and students are learning to be nurses, it is common and appropriate to be discussing nursing diagnosis. It’s not always taught well, IMHO, so I try to clarify the concept that nursing dx is not derivative of or dependent on medical dx. Nursing dx is about teaching nursing students to think like nurses, not appurtenances to physicians. For example, a nursing dx you might make based on your nursing assessment: risk for altered skin integrity, pressure injury. There are many reasons this might occur, and the nurse is the one responsible for finding them, addressing them, and evaluating how well their interventions worked. Our scope of practice defines this as an independent nursing responsibility both professionally and legally. Nursing school focuses on nursing diagnoses in the same way that PT school focuses on PT assessment and planning or med school focuses on medical diagnoses. We all have areas of overlap, of course, in education re anatomy, physiology, and therapeutics of many kinds. But we all have individual areas of expertise and responsibility. Keep that in mind. 

There are many, many times when a hospital inpatient admission is based on a nursing diagnosis. The fact that nsg dx is not always taken into account by EMR systems is a reflection of EMR being a financial tool, I.e., for billing purposes. Insurance reimbursement is almost universally based on medical dx and interventions, a practice which subtly devalues nursing both by rendering it invisible and by deeming it worthless. 

[neuron]

1 hour ago, Hannahbanana said:

 

There are many, many times when a hospital inpatient admission is based on a nursing diagnosis. The fact that nsg dx is not always taken into account by EMR systems is a reflection of EMR being a financial tool, I.e., for billing purposes. Insurance reimbursement is almost universally based on medical dx and interventions, a practice which subtly devalues nursing both by rendering it invisible and by deeming it worthless. 

Nurses HAVE to know medical diagnosis or be familiar with them. Nursing diagnosis are simply not used. Sure we have to know them in our assessments, what impaired skin integrity is or ineffective airway clearance, but when push comes to shove, PNA viral or bacterial  unspecified (as an example) will be primary or admitting when entering them in the medical record, not ineffective airway clearance.  The duty of the nurse is to assess the patient yes for ineffective airway clearance but when reporting this to the doctor this all goes out the window. It's what you did for the patient, and if there is a CXR in order. It's going to be about what the nurse does, not what the nursing dx is. That won't be reported on ANY documentation. 

Impaired skin integrity will be documented but probably not in those terms. 

[Hannahbanana, BSN, MSN]

This is why I mentioned overlap. Of course nurses have to know a lot about physiology, medical diagnostics, and medical conditions.

The point of nursing diagnosis is to make a decision based on nursing assessment and treat it as a nurse would. These are not mutually exclusive. In the example you give, the medical dx of pneumonia, the nurse is legally obligated to implement parts of the medical plan of care, such as giving prescribed medications and treatments required to be RX'd by a licensed provider (MD, DO, NP, etc.).

In most places the unit clerk is responsible for seeing that the CXR gets scheduled and done as part of the medical plan of assessment and care. The nurse would be responsible for seeing that the report is forthcoming.

Nursing's diagnosis of ineffective airway clearance (if that's what's happening c this pt) would prompt nursing to institute NURSING measures as appropriate, like raised head of the bed, C&DB q 1-2 hrs, hydration, and continued monitoring for changes in sputum, SOB, etc.  The nurse would likely also assess for activity tolerance (SOB at what level of activity?) and modify activity appropriately. What other things might a nurse do for a pt c ineffective airway clearance, activity intolerance, and whatever else you see in this pt? Teach about meds, teach about reporting sx/sx like changes in SOB, sputum color, or pain, teach about smoking cessation, family support, ask about whether there's mold or other known risk factors in the home, ask those four important questions before discharge (who lives c you? Who shops and cooks? How many stairs do you have to climb to get him? How will you get your meds and f/u care?-- all shown to have significant effects on readmissions) ....

NONE of this requires MD input. This is, explicitly, what the nursing practice act in our state requires you to do: Make an independent nursing assessment, derive a nursing plan of care, implement it/delegate it, evaluate it, and adjust it PRN.

This is why health insurance pays for hospitalization-- for NURSING care in addition to the provision of medical care.

And again, the EHR/EMR is catalogued by medical diagnosis solely for the purposes of financial reimbursement. That doesn't mean nursing assessment and diagnosis based on it never appears in a chart. On the contrary, I have seen a number of legal cases where lack thereof was a critical factor. Think like a nurse, because that's the standard to which you will be held.