Proper Skin DX

[txdon]

Need clarification, is it okay to put on the treatment order dx: contact dermatitis? The nurse originally said it was a blister on the heel. Then we had a regional nurse evaluate and she said it was contact dermatitis. The nurse who originally assessed the wound was upset because she said she was making a "medical" dx, but don't we do that all the time when we write a T.O? The dr. gives the order and we write in the dx. We wouldn't write a nursing dx like impaired skin integrity. I need clarification.

[tyvin, BSN, RN]

When we take verbal orders over the phone the doc tells us what the Dx is. We as nurses cannot diagnose and contact dermatitis is a Dx. There fore documentation should show compromised area blah blah, start Tx sheet blah blah not a specific Dx until a doc assesses.

If we have a good relationship with the doc we can advise Dx but we can't do it on our own. We of course can write a nursing Dx on the Tx sheet in the interim alteration in blah blah etc ...

[Whispera, MSN, RN]

Unless the regional nurse who evaluated the patient's skin is an advanced practice nurse (APN), she isn't qualified or allowed to diagnose a medical condition in medical terms. She can only use nursing diagnoses. If she IS an APN, she can make medical diagnoses.

Whoever made the medical diagnosis would have to write it somewhere or sign where you wrote it for her, somewhere.

I think using "impaired skin integrity" or "blister on the heel" is good enough for what you need to do, however. You can still implement the nursing care plan with either of those, can't you?

[tewdles, RN]

Agree with other responses. Nurses need to use the nursing diagnosis on the medical order unless the physician provides a specific medical diagnosis...the obvious exception is the APN in this scenario.

[jones.rn]

Is she a wound specialist? Because she may be certified.

[txdon]

She is wound certified (WOCN). Would that make a difference? I just wasn't sure because I have never seen a nurse write a nursing dx on an order, it's always a medical dx. Contact dermititis is such a generalized category. Just wanted to get clarification.

[Whispera, MSN, RN]

Certification as a wound specialist doesn't give the right to make medical diagnoses unless the nurse is an advanced practice nurse. Might she have talked to a doctor or APN and that person made the diagnosis?

[CapeCodMermaid, RN]

Perhaps the regional nurse wanted it documented as a 'contact dermatitis' so y'all wouldn't get dinged for an acquired pressure ulcer. That being said, she can not diagnose.

[txdon]

The wound nurse is not an Advanced Practice Nurse. Thanks for clarifying that. I plan on giving an inservice on this very matter.