Prioritizing "Medical" Diagnoses

[sparrowSN]

I am a senior nursing student currently doing rotation in Geriatrics and Med-Surg concurrently. The week before last week I had a great time in the ER, day surgery and OR. Then last week I had my second Geriatric clinical. (Our clinicals are 12 hour shifts for two days.) I have told the class instructor that I don't like doing geriatric nursing. I would like to go into OR, ER, or ICU nursing. However, I show up an hour early to clinical by half an hour or more, because I want to do this well. I feel sorely misjudged!

The instructor thinks that just because something is not my first choice she's assuming that I am not doing a good job at it. Since I show up before the instructor, she doesn't know I've been there early and that I look up things of interest to me during that time. She's never in the room when I do any assessments. When she was in a patient's room with me at my last clinical, she proceeded to interrupt my social needs assessment by performing a physical exam on a patient that I had already done a physical assessment on. According to my other instructors my assessment skills and write-ups are excellent (I peer mentor for the junior nursing students). However, according to the geriatric clinical instructor (this is her first year teaching) my assessments need work. The NH is USUALLY well staffed with CNAs (amazing isn't it!), so I have had time to sit and address social needs (again, amazing) with the five patients that I was assigned for 12 hours. Occasionally, they have an urgent need and I'm right on top of it, i.e. dropping O2 sats and SOB, etc. This instructor keeps telling me that I need to work on my time management. I don't know what she's talking about and neither do my peers when I ask them what they think. (I'm the class president.) Like I said, she shows up at the nursing desk when I'm there and watches me chart and then leaves.

On my clinical write-up, the instructor told me that I had the nursing diagnoses that were a priority correct, but I was not focusing on the correct "medical diagnosis" which goes at the center of the "wheel of thinking" with the nursing dx as the "spokes". I know that RNs at the NH have to function more independently of the docs than at the hospital, but this is way independent for my liking. (It's a lot easier when the doc prioritizes the med dx for you at the hospital. And if I assess and come up with a conflicting medical diagnosis as a priority, do you really think the doc will go for it? Yeah, right.) So, how do geriatric RNs decide what is the most priority "medical diagnosis"? I get the nursing dx, just not the med dx. Thanks in advance for your input.

[CoffeeRTC, BSN, RN]

HuH? I'm not sure what your instructor is getting at. I've been in LTC for about 8 yrs now.... and thank you for realizing its not for you...Not everyone is a LTC nursse, OB, ICU, etc. As far as prioritzing care.. My routine..get report, eye ball all of the residents, pass meds, call md when needed, chart, pass meds. Assessments usually happen during med pass unless something pops up. Since Ive been at the same place for I while I usually know just about all of my res top dx so when checking on them I will focus on those and an new acute problems. The ABC's allways apply. As you know.. no one really has time to sit down and talk to the resident for long periods of time and as far as psych social assessments, they are done by the social workers in LTC. As far as using nursing DX, those are in the care plans done by the assessment coordinators and floor nurses in our place rarely see them. We rarely see NANDA used in our care planning. What Im trying to say is that when I see a resident.. Mrs Jones I look at her and think..Okay she's a diabetic, COPD, HTN, PVD, and multiple decubs. Is she alert, what's her blood sugar, O2 sat (on o2 at 3L) whats her coloring, how is she positioned in bed, when was she last turned, does she need changed, how are her dressings. this all normally happens while doing meds or dressing changes.

[Catsrule16, RN]

Apparently your Clinical Instructor has no idea how a NH operates. Quality of Life and Quality of Care are the two most important areas of focus in a NH. Are they reaching the maximum potential for what is going on with the resident? Is there life in the facility fulfilling to the resident? NH are not required to write care plans in NANDA format.

Care Plans in NH do include medical diagnoses but focus more on the quality of care and life improvements.

So what if a resident has elevated blood sugars from being non-compliant. Are those elevated blood sugars interfering with the quality of life? Are there any negative outcomes from the blood sugars being elevated? How long have they been elevated? Could what we preceive as elevated be normal for that person?

I have polycystic ovaries and for me normal blood sugars range from 50 to 100. I do not have symptoms of problems at 50.

When I was writing care plans in NH, when I needed to prioritize medical problems, I focused on those that would effect the resident's life first, A seizure disorder, safety, possible extension of a CVA, aspiration, drug interaction, etc.

Don't know if I helped. Hope so. Good Luck anyways.

[CaliforniaRN]

SparrowSN-- It seems like you have serveral problems going on. One thing you need to do is get a handle on the expectations that your instructor has of you. Those need to be ironed out right away. Communication, Communication! If need be, have another trusted nursing instructor with you when you decide to talk things over. It's best if you have two sets of ears. By now you are completely aware of the hoop jumping that needs to be done in order to graduate from nursing school. Take care of this issue so that there are no suprises come graduation time!

Now. About the nursing diagnosis. I work in long term care, and I do use NANDA. Though my long term care plan is based on functional patterns, NANDA language serves me well. You may want to discuss the MDS (Minimum Data Sets) with your instructor. If she is a clinical instructor who has worked in long term care, she will know and understand that the MDS drives the care planning decision and nursing diagnosis, not the main medical diagnosis. If you'll remember, nursing diagnoses are descriptions of a patient's response to illness (and wellness, for that matter!). While a medical diagnosis may get you on track for nursing monitoring, your MDS assessment process will most definitely guide you in your decision making for comprehensively care planning your patient's issues. And since it is based on functional patterns and NOT on medical diagnosis, you will not get far trying to fit it to a medical diagnosis model. It is completely in nursing language. Nursing language does not translate into medical language (doctor-speak!) easily and vice versa. Your long term care plan will not look anything like an acute care plan.

Now, if you are talking about the short term care plan, that is another issue. That will look similar to an acute care plan as it addresses a resident's needs during an acute illness. And you may need to understand the primary medical diagnosis in order to care plan your nursing interventions. Again, NANDA is the standard, and you will need to use nursing process to define your nursing diagnosis. You can still base this on functional patterns, but again, it is more difficult to do that as you will be fitting it to a a medical diagnosis(doctor-speak) which does not always translate to nursing language without some difficulty. But, as you know, many nursing diagnosis books list the medical diagnoses in the index to make this translation easier for nurses. (Nurses become biligual in this manner!)

In conclusion, I work extensively with nursing students and faculty through my work with our local student nurse mentoring project. One area that nursing schools really need to look at is the power plays with which some nursing instructors sabotage nursing students. This is level one of nurses eating their young (a well known fact in nursing) and makes for early burnout of new nurses right from the start. That is why I urge you to talk with your instructor and get things ironed out. You need to protect your career and nuture it. No one will do that for you. You are very close to the end, and you must not jeopardize a wonderful career. Problem solving this issue will give you excellent experience at working on a difficult problem, and you just may find out that your instructor thinks very highly of you. Good luck!

[psychomachia]

SparrowSN writes: "I have told the class instructor that I don't like doing geriatric nursing. I would like to go into OR, ER, or ICU nursing."

ME: Don't take this the wrong way, but NEVER tell the instructor what you DON'T like to do, since you're guaranteed to have the one instructor who LOVES whatever you don't. Always try to find out what the instructor's "nursing" interest is, and play it up as if you really like it, even if you don't.

Part of nursing school is learning to play the game...say what they want to hear, write what they want to read, and swear you love being a nurse more than ANYTHING in the world...

And if you truly don't like geriatrics, then I would consider either pediatrics or NICU, 'cause the ER and ICU are FULL of old people.