The Usefullness of Nursing Diagnosis in Medical Decision Making

amzyRN · Dec 1, 2007

I think you guys are focusing on the time commitment of MD vs DNP too much. Even if the MD route is long by just a few years, you're not factoring in how difficult the path is. If you know someone who is going through medical school or residency, you'll see how many hours they have to put in. Wake up at 4 or 5 AM, go to hospital, go home maybe at 8 PM, everyday. Then they have to study to pass all those tests. Medicine is very difficult intellectually, emotionally, and physically.

I think that nursing can be just as difficult. I think the philosophical view of the human being is viewed differently through the medical model versus the nursing model, but in practice both nursing and medicine are very demanding professions, intellectually, emotionally, and physically. For example, the nurse is the first line of defense and the one that keeps the patient alive while they are in the hospital. If the nurse doesn't know about the science of medicine, the patient may die. From what I have learned so far, which is very little considering I've just started a 2nd degree BSN program, is that the nurse is responsible for the patients life the bulk of the time in the hospital. The docs are busy running from patient to patient. How can a doc make an accurate diagnosis in just a few minutes of seeing the patient? From the nurse's assessments of the patient. It's a symbiotic relationship in the hospital, but nurses get little of the credit. From a science point of view, having a degree in molec. cell. bio., with completion of all pre-med requirements, I think medicine does go into more depth with respect to biochemistry, pharmacology, physiology, etc...But, the question becomes, is that really required for making accurate diagnoses and helpful interventions for patients. Does knowing in-depth biochemistry of how every electron is supposed to flow make a person a more qualified decision maker. At times in the past I believed that it did, but now am unconvinced. But, I digress...In nursing, the course work is not that much in depth with respect to how every electron flows, but very in depth when it comes to interacting with people, as human beings, and that is a lot. There seem to be more gray areas in nursing, where medicine attempts to have black and white answers and the answer is just a fix it pill. All that study, for that small answer, seems ashame. The human condition must be larger than that and I believed that nursing shared that view. In short, I don't think people just go into nursing because they think it's easier, at least that's not what drew me to it.

core0 · Dec 1, 2007

i think that nursing can be just as difficult. i think the philosophical view of the human being is viewed differently through the medical model versus the nursing model, but in practice both nursing and medicine are very demanding professions, intellectually, emotionally, and physically. for example, the nurse is the first line of defense and the one that keeps the patient alive while they are in the hospital. if the nurse doesn't know about the science of medicine, the patient may die. from what i have learned so far, which is very little considering i've just started a 2nd degree bsn program, is that the nurse is responsible for the patients life the bulk of the time in the hospital. the docs are busy running from patient to patient. how can a doc make an accurate diagnosis in just a few minutes of seeing the patient? from the nurse's assessments of the patient. it's a symbiotic relationship in the hospital, but nurses get little of the credit.
this is true and not true. first i don't think that nursing has the monopoly on humanistic care. care of the person is important and i spend as much time on social situations as medical. second an accurate diagnosis is made the way that it has always been made. a careful history and physical backed up by tests to confirm the diagnosis. nursing assessments are of very little use here. what i rely on from nursing is to alert me to changes in the patients condition and to assess psychosocial conditions that are more observable over long periods of time.
from a science point of view, having a degree in molec. cell. bio., with completion of all pre-med requirements, i think medicine does go into more depth with respect to biochemistry, pharmacology, physiology, etc...but, the question becomes, is that really required for making accurate diagnoses and helpful interventions for patients. does knowing in-depth biochemistry of how every electron is supposed to flow make a person a more qualified decision maker. at times in the past i believed that it did, but now am unconvinced. but, i digress...in nursing, the course work is not that much in depth with respect to how every electron flows, but very in depth when it comes to interacting with people, as human beings, and that is a lot. there seem to be more gray areas in nursing, where medicine attempts to have black and white answers and the answer is just a fix it pill. all that study, for that small answer, seems ashame. the human condition must be larger than that and i believed that nursing shared that view. in short, i don't think people just go into nursing because they think it's easier, at least that's not what drew me to it.

many of the problems that you describe are a function of short hospital admissions mandated by insurance. we used to do social admissions and could keep someone around until they were "all better". on the other hand if you are a medical provider in the current day and age, you had better understand you biochemistry and pathophysiology. the patients have become much sicker and have a tendency to decompensate faster. combine this with the constant shortage of icu beds and you are taking care of patients that in the past would have been in a monitored bed. this means that you have very little margin for error.

interacting with people is important, but in essence people are in the hospital for medical care that cannot be provided at home.

david carpenter, pa-c

amzyRN · Dec 1, 2007

Many of the problems that you describe are a function of short hospital admissions mandated by insurance. We used to do social admissions and could keep someone around until they were "all better". On the other hand if you are a medical provider in the current day and age, you had better understand you biochemistry and pathophysiology. The patients have become much sicker and have a tendency to decompensate faster. Combine this with the constant shortage of ICU beds and you are taking care of patients that in the past would have been in a monitored bed. This means that you have very little margin for error.
Interacting with people is important, but in essence people are in the hospital for medical care that cannot be provided at home.
David Carpenter, PA-C

Above, you say that nursing assessments are not of use for diagnosis, why is that the case? Are you saying that the provide little input in medical diagnoses?

You then mention that understanding biochemistry is very important, which I agree. And I'm glad that I do understand biochemistry, but I also understand that pharmacology will only do so much. It usually only affects a receptor, a human being is a whole system that includes a psyche that impacts the endocrine system, that impacts everything in the body, etc...This is only from a science point of view. If we just give a pill, and then it's bye bye, that's not enough. I haven't looked up the data yet, but will when I have time, but I bet that pharmacologic therapies, that work at receptors are not the only thing that's causing the patient to get better. Medicine and healing are much bigger than that. To say that we can predict how the body work in as a whole is not factual. In fact, many medications that we use, the mechanism is unknown. I think a little more heart goes a long way and the nursing philosophy (not practice necessarily) includes recognizing that a human being is an irreducible whole. In short, I do think biochem and such are important, but not the whole picture. And the docs and others that use medical process/model, are not the only ones doing the thinking part either.

J

core0 · Dec 1, 2007

above, you say that nursing assessments are not of use for diagnosis, why is that the case? are you saying that the provide little input in medical diagnoses?
part of the problem is the timing. by the time the original nursing assessment my initial plan has been done for a while so there is little to no input in my initial diagnosis. the next part is focus. many of the nursing assessment pieces are preventative. for example skin breakdown is important but unless someone is being admitted for a decub. the final problem is the documentation. frequently the documentation is inaccessible. if it is accessible it is usually unreadable. you can only go through so many pages of "potential for impaired skin integrity due to immobility ...." so many times before your eyes glaze over.
generally i do use nursing assessment but i get it from the nurses. i have found that three questions get most of what i need. any problems? any concerns? any questions? i try to keep the nurse updated with the plan. so, from my point of view, nursing assessment is rarely helpful for initial diagnosis and the formal nursing assessment is not too helpful due to taxonomy.
you then mention that understanding biochemistry is very important, which i agree. and i'm glad that i do understand biochemistry, but i also understand that pharmacology will only do so much. it usually only affects a receptor, a human being is a whole system that includes a psyche that impacts the endocrine system, that impacts everything in the body, etc...this is only from a science point of view. if we just give a pill, and then it's bye bye, that's not enough. i haven't looked up the data yet, but will when i have time, but i bet that pharmacologic therapies, that work at receptors are not the only thing that's causing the patient to get better. medicine and healing are much bigger than that. to say that we can predict how the body work in as a whole is not factual. in fact, many medications that we use, the mechanism is unknown. i think a little more heart goes a long way and the nursing philosophy (not practice necessarily) includes recognizing that a human being is an irreducible whole. in short, i do think biochem and such are important, but not the whole picture. and the docs and others that use medical process/model, are not the only ones doing the thinking part either.
j

we don't know exactly how some medications work, but we know the effects and side effects. while there are metric tons of material on the influence on mind and physiology, there is very little good clinical validation on interventions. if you are talking about social interventions, they are important. if you are talking about using psycho-social manipulation instead of medications then i tend to favor evidence based solutions.

david carpenter, pa-c

amzyRN · Dec 1, 2007

We don't know exactly how some medications work, but we know the effects and side effects. While there are metric tons of material on the influence on mind and physiology, there is very little good clinical validation on interventions. If you are talking about social interventions, they are important. If you are talking about using psycho-social manipulation instead of medications then I tend to favor evidence based solutions.
David Carpenter, PA-C

First, you did not address my first question regarding your statement that nursing assessments are of little use in diagnosis. I am not convinced that that is true. And if it is indeed true, then why do nurses need to know basic anatomy and physiology. Second, "evidence based" is still biased because there cannot be controls for everything, thus, there is still bias in EBP solutions. We live in a world of uncertainty, physics tells us that, and to ignore other possibilities is fallacy. Medicine and nursing are practices that means that we practice not that we are masters, but always practicing. Third, define psycho-social manipulation. Does this mean that anything that conflicts with your line of thinking is manipulation? We are all biased in some respects, and medical science is a practice and a discourse, not set in stone.

J

amzyRN · Dec 2, 2007

I just thought I'd post a link that I found while contemplating what I had said in an earlier response that I took to mean that medicine had absolute answers and can deliver the best answer based on EBP. These were my impressions. The following link takes a look at medical science from a philosophical view, mainly a postmodern perspective. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1769504

I was also, taken aback and want some clarification, if possible, and when convenient, about the the notion that nurses contribute little to diagnosis of illness in hospitals. Is that really true, that nursing assessments are meaningless? Thanks for your time and ideas,

J

core0 · Dec 2, 2007

first, you did not address my first question regarding your statement that nursing assessments are of little use in diagnosis. i am not convinced that that is true.
i though i did address it. nursing diagnosis is of little use in forming a medical diagnosis for the reasons that i listed above (timeliness, accessibility and relevance). good nursing assessment is important for telling how the patient is responding to the plan. it is also important to see if the patient is getting better or worse. in the grand scheme of things, in my opinion (and that of many experienced nurses) nursing diagnosis is of little use (and less use to medical diagnosis).
and if it is indeed true, then why do nurses need to know basic anatomy and physiology.
nurses need to know basic and advanced physiology to carry out plans and do nursing assessments. if you are giving a medication you had better know more than basic physiology. if you are running a multiple drips in the icu you had better know more than basic physiology.
second, "evidence based" is still biased because there cannot be controls for everything, thus, there is still bias in ebp solutions. we live in a world of uncertainty, physics tells us that, and to ignore other possibilities is fallacy. medicine and nursing are practices that means that we practice not that we are masters, but always practicing.
i am not sure what you mean here. physics on a macro level tells us that there is chaos and there is order. on a micro level it means that covalent bonding of epinephrine at the b-1 adrenergic receptor (to use one example) causes increased cardiac rate and output. this is well understood. wishful thinking isn't going to change this.
third, define psycho-social manipulation. does this mean that anything that conflicts with your line of thinking is manipulation? we are all biased in some respects, and medical science is a practice and a discourse, not set in stone.
j

manipulation may be a poor choice here, but includes that technique that must not be named on a nursing board. i agree medicine is a practice and not set in stone. however, we use the best practices as defined by our practice environment.

david carpenter, pa-c

amzyRN · Dec 2, 2007

this is true and not true. first i don't think that nursing has the monopoly on humanistic care. care of the person is important and i spend as much time on social situations as medical. second an accurate diagnosis is made the way that it has always been made. a careful history and physical backed up by tests to confirm the diagnosis. nursing assessments are of very little use here. what i rely on from nursing is to alert me to changes in the patients condition and to assess psychosocial conditions that are more observable over long periods of time.

part of the problem is the timing. by the time the original nursing assessment my initial plan has been done for a while so there is little to no input in my initial diagnosis. the next part is focus. many of the nursing assessment pieces are preventative. for example skin breakdown is important but unless someone is being admitted for a decub. the final problem is the documentation. frequently the documentation is inaccessible. if it is accessible it is usually unreadable. you can only go through so many pages of "potential for impaired skin integrity due to immobility ...." so many times before your eyes glaze over.

sounds a little demeaning to me.

generally i do use nursing assessment but i get it from the nurses. i have found that three questions get most of what i need. any problems? any concerns? any questions? i try to keep the nurse updated with the plan. so, from my point of view, nursing assessment is rarely helpful for initial diagnosis and the formal nursing assessment is not too helpful due to taxonomy.

but don't nurses do the initial assessment. that's what i've been taught so far. and i've also been taught that nursing diagnoses aren't used. what i've learned about nursing is that nurses are the first ones to assess the pt's condition and the doc/pa/np comes in and finds out what the nurse observed, then does their own assessment, tests and diagnosis. that's not a superficial role. also, the nurse is supposed to catch medical errors by docs and the like.

j

amzyRN · Dec 2, 2007

Core0,

You say covalent bonding of epinephrine to the B-1 adrenergic receptor causes increased increased heart rate and cardiac output and wishful thinking will not change that. Well, I beg to differ. There is never any guarantee that something will happen, i.e., something may prevent the epinephrine from binding to the receptor. Though it may be unlikely, still possible. Any number of things can prevent binding to the receptor, like perhaps and unknown antagonist at the receptor prevents the binding. And even if it binds to the receptor, another factor may inhibit the response inside the cell. We cannot predict with the accuracy you claim,

J

core0 · Dec 2, 2007

this is true and not true. first i don't think that nursing has the monopoly on humanistic care. care of the person is important and i spend as much time on social situations as medical. second an accurate diagnosis is made the way that it has always been made. a careful history and physical backed up by tests to confirm the diagnosis. nursing assessments are of very little use here. what i rely on from nursing is to alert me to changes in the patients condition and to assess psychosocial conditions that are more observable over long periods of time.
part of the problem is the timing. by the time the original nursing assessment my initial plan has been done for a while so there is little to no input in my initial diagnosis. the next part is focus. many of the nursing assessment pieces are preventative. for example skin breakdown is important but unless someone is being admitted for a decub. the final problem is the documentation. frequently the documentation is inaccessible. if it is accessible it is usually unreadable. you can only go through so many pages of "potential for impaired skin integrity due to immobility ...." so many times before your eyes glaze over.
sounds a little demeaning to me.
sorry but its the way it is. life is often unlike school.
generally i do use nursing assessment but i get it from the nurses. i have found that three questions get most of what i need. any problems? any concerns? any questions? i try to keep the nurse updated with the plan. so, from my point of view, nursing assessment is rarely helpful for initial diagnosis and the formal nursing assessment is not too helpful due to taxonomy.
but don't nurses do the initial assessment. that's what i've been taught so far. and i've also been taught that nursing diagnoses aren't used. what i've learned about nursing is that nurses are the first ones to assess the pt's condition and the doc/pa/np comes in and finds out what the nurse observed, then does their own assessment, tests and diagnosis. that's not a superficial role. also, the nurse is supposed to catch medical errors by docs and the like.
j

i can tell you what 7 years of being a pa and another 10 working in the medical field has shown me. i would tell you that 9/10 physicians couldn't tell you what a nursing diagnosis was if you showed it to them in the chart. i can tell you that in 7 years i have never seen a physician/pa/np use the nursing diagnosis to form a plan.

now i work in surgery so it is somewhat different, but not completely different in medicine. i get called that pt x is in the er. i go to the er and talk to the nurse/resident/physician and find out where the patient is and what they are here for (which is frequently different than what we were told over the phone). i go in get a history do a physical exam, order any tests and initiate treatment (or tell them i don't think that they need to be admitted have them follow up in clinic). i never see a nursing care plan. i usually talk to the nurse and get their impression because er nurses tend to be a pretty good judge of things. this is how it tends to work in the real world. the one nice thing that happens is that the nurse usually fills out the medication sheet with all the meds (in private practice i had to try to figure this out).

in clinic the nurses don't do any nursing plans or diagnosis. they room the patient, reconcile the meds and do any teaching when we are done.

on direct admits i look up the patients record and then go examine the patient. i formulate the plan and order any tests.

on the subject of using the nurses assessment, the first thing i was taught is never use any one elses assessment ever. if you are going to make a mistake, make it yourself, don't perpetuate someone elses. i will look at other assessments to see when a change occurred. for example if i don't hear bowel sounds i will look back and see when they were last documented. other than that i do my own work and thats the way others generally do it. there may be places such as the er where nurses do the first assessment but i don't work there.

david carpenter, pa-c

amzyRN · Dec 2, 2007

I can tell you what 7 years of being a PA and another 10 working in the medical field has shown me. I would tell you that 9/10 physicians couldn't tell you what a nursing diagnosis was if you showed it to them in the chart. I can tell you that in 7 years I have never seen a physician/PA/NP use the nursing diagnosis to form a plan.
Now I work in surgery so it is somewhat different, but not completely different in medicine. I get called that PT x is in the ER. I go to the ER and talk to the nurse/resident/physician and find out where the patient is and what they are here for (which is frequently different than what we were told over the phone). I go in get a history do a physical exam, order any tests and initiate treatment (or tell them I don't think that they need to be admitted have them follow up in clinic). I never see a nursing care plan. I usually talk to the nurse and get their impression because ER nurses tend to be a pretty good judge of things. This is how it tends to work in the real world. The one nice thing that happens is that the nurse usually fills out the medication sheet with all the meds (in private practice I had to try to figure this out).
In clinic the nurses don't do any nursing plans or diagnosis. They room the patient, reconcile the meds and do any teaching when we are done.
On direct admits I look up the patients record and then go examine the patient. I formulate the plan and order any tests.
On the subject of using the nurses assessment, the first thing I was taught is never use any one elses assessment ever. If you are going to make a mistake, make it yourself, don't perpetuate someone elses. I will look at other assessments to see when a change occurred. For example if I don't hear bowel sounds I will look back and see when they were last documented. Other than that I do my own work and thats the way others generally do it. There may be places such as the ER where nurses do the first assessment but I don't work there.
David Carpenter, PA-C

Nursing diagnosis and the use of were not what I was concerned about. I don't know if nurses actually use those in practice and I don't care if they do. My concern was that you seemed to be saying that a nurses actual assessment, like "somethings not right here or something is not wrong here" are ignored by docs. I'm certain that we use our own assessments, but don't we collaborate to come to a conclusion together. Or do docs and the like say in essence "here, you moron, go do the teaching." That's what concerned me was the demeaning tone. I recognize and respect your expertise in your field, but when you make sweeping generalizations, I feel compelled to question you. I also feel compelled, as someone with a b.a. degree molec. and cell biology, with a love of biochemistry, that it ain't the whole story. And we can never say that just b/c something happens to bind to a receptor that that binding will have the same effect all of the time. Mutations and changes can happen in the cell. Genes can change the receptors, etc. The body is infinitely complex, and I doubt we will ever understand it's mystery and docs and others who know it all, should be a little more humble in their practice.

Will getting a doctorate finally get people to stop assuming and treating nursing and nurses like morons? Will it validate nursing as a worthy pursuit?

J