The Usefullness of Nursing Diagnosis in Medical Decision Making

[n_g]

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.

[core0]

I remember some nursing leader being quoted as saying, back when I was in nursing school in the Dark Ages, that one of the problems nursing faced as a group was that, "All nurses are expected to assume that all doctors are competent until proven otherwise, but each individual nurse has to prove her(/his) competence to each individual physician." Unfortunately, this phenomenon is largely still true today.

Nice post. I will take one portion (which I hope is not out of context).

This is the essential problem with nursing assessment and nursing diagnosis. Nurses are professionals and as such should be allowed to manage their job in a manner which is appropriate. In theory nursing assessment and nursing diagnosis are part of that professional practice. However, nurses are employed by hospitals. Next to the Army (in my opinion) the most soul sucking organizations in the history of mankind.

For my example. Look at a physician note. Mine are usually longer for billing purposes but this is a perfectly legal chart note:

S: PT feels OK

O: VSS afebrile

Abdomen soft positive bowel sounds no MTO.

A: Bacteremia - on antibiotics

P: Follow

Now look at a nursing assessment. These are usually multifold papers with hundreds of check boxes and places to write in nursing diagnosis. Even on computerized systems it is screens and screens of check boxes.

Why do these exist. Originally it was a way to document nursing assessment and diagnosis. The checkboxes evolved because no one uses this and the interest is to get it out of the way. However, there is a darker and more sinister point here. Hospitals routinely use these not only to document nursing assessment but also to ensure that nurses are doing what nursing managers think that they should be doing. It is more important to document all the supposed interventions (whether they apply to the patient or not) than actually provide nursing care to the patient. Since nursing management doesn not have the ability to assess how the nurse is doing they use this as a surrogate. That is the true tragedy of nursing assessment.

David Carpenter, PA-C

[DaisyRN, ACNP]

in a word: "wow."

lots of topics to discuss within this one little thread... *haha*

let's look at an example:

56 yr old english teacher presents to you with a stroke and irreversible focal neurological deficits. she cares for her 2 grandchildren in junior high school. her husband is deceased, and her nearest son lives 3 hours away... here's the difference in approach from medical vs. nursing...

nursing diagnoses:

1. caregiver role strain related to debilitating illness as evidenced by l sided hemiplegia... etc. (it's been a while since i've even thought about a nursing dx so bear with me... *lol*)

2. impaired coping related to debility...etc.

3. altered tissue perfusion related to immobility as evidenced by paralysis...

4. risk of aspiration related to new illness as evidenced by difficulty swallowing and failed swallow study...

5. fear..

and the list goes on... (and on... and on...)...

(here's a list if you're interested: http://www.everything2.com/index.pl?node_id=1014512)

medical diagnoses:

1. cva

2. deconditioning (possibly)

3. htn (maybe?)

4. dmii (if she has it...)

it's not that the nursing diagnoses aren't important, per se, but they are looking at how the medical diagnosis affects the patient's adls, quality of life, etc... and reminds the rn what he/she can do to help the patient cope with the illness, prevent aspiration, prevent decubitus ulcers, etc... not how to take care of the medical problem at hand. does that make sense? that is why the nursing assessment/diagnoses aren't relied upon solely for medical diagnosis and treatment. yes, it is the md/provider that orders social services consult, wound care, physical therapy, dietician, neuro consults, etc. and its the nursing assessment and conversations with the nurse (that has gotten to know the family/patient) that help guide these type of orders.

[amzyRN]

It seems like a complete view would combine these views of the issue at hand, i.e. the response to illness and illness itself, because illness affects response and vice versa. Disease does not exist in a vacuum and the response affects the progression of the illness. Thanks for all of your interesting and appreciated thoughts,

J

[CraigB-RN, MSN, RN]

I get the feeling that some posters are using nursing assessment and nursing diagnosis as interchangable terms. They aren't

nursing assessment is something that is ongoing, and in my experience, way to many years of experience, it is something that is important. it's my assessment that identifies the CVA in the intubated patient, it's the assessment that identifies the possibility of a PE. ANd in 30 years I can count on one hand the number of times I was ignored when I identified one of those things.

Nurisng diagnosis on the other hand is a waste of time and paperwork at worse and at best a way of thinking, to set out priorities. in planning care. ( I've been doing this long enough to remember the discusions when nurisng dx came out, we were going to be able to bill for our sevices because of the nursing diagnosis.) Nursing dx is way to generalized, it's ok for a staff nurse to recognize hypoperfusion and not care exactly what is causing it, but when the responsible provider, MD, DO, NP, PA, DDS, DPM whatever gets there, they have to narrow things down when possible in order to direct treatment.

Oh how I miss the old problem lists. It was much easier to see what needed to be done with each patient. That problem list and sitcky notes left for the MD always seemed to get things done.

[TachyBrady]

I don't think that coreo is saying that nurses' observations should be ignored- he's not saying that at all. What he is saying is that when the status of a patient has changed, he wants to see the patient himself, because he and the physician is ultimately responsible for the care of the patient, not the nurse.

As far as the initial assessment of the pt. by the nurse, it is hard to blame the doctors for not reading the nursing assessments. They're going to have to complete a hx. and physical examination themselves anyway, and they are very busy, so I'm sure that a lot of times they just don't have time to read the nursing notes.

Anyone who has worked in a hospital knows how crucial a role the nurses play-- they are the eyes and ears of the physicians. However, the physicians are still the minds, and since they are the ones who are ultimately responsible for the patient, they want to be there to assess the patient and make sure that the decisions are made properly.

With all due respect, as a floor nurse, I am ultimately responsible for my care of a patient. My nursing assessments ARE NOT done for the benefit of the PCP but rather document the pt's condition for the medical record and also provide a baseline used for tracking changes in condition. Nursing assessments are passed on from shift to shift in order to detect changes and ensure continuity of care.

To state that "the physicians are still the minds" is demeaning and false. I am my own eyes and ears and mind. I am completely responsible for my nursing care of my patients. I will notify the PCP with issues that concern medical treatment; otherwise, my nursing practice is dictated by MY education and experience (not the doctor's!!!). At my place of work, physicians are appreciative and respectful of nursing's independent assessments, interventions, and judgement when they need addressing.

Nursing diagnoses are a whole different can of worms!

[elkpark]

I think what I meant to say in my post was that I have my own mind and am not just a set of eyes and ears. That's frankly rather insulting. Everyone has their own mind, including the physician and his own eyes and ears as well. The eyes and ears better be connected to the mind or we are in big trouble here.

Also, nurses aren't supposed to follow orders that don't make sense, so they have got to think. Anyone who just blindly follows orders shouldn't be in charge of other peoples lives. I wouldn't want some mindless set of eyes and ears as my nurse. I'd want a functioning brain between the ears.

I also think that it is a collaborative effort between the health care team. Together we can make a difference in peoples lives. Doctors, nurses, NPs, PAs, can work together and respect each other.

I'm a little worried now though about the prospects for myself in nursing. If even NPs are looked down upon, how can anyone stand it? Anyway, thanks for your post,

J

Just to clarify, I was not suggesting that nurses don't have minds, or need to use them -- of course, we do, and any savvy physician knows full well that observant and knowledgeable nurses have saved her/his butt on many occasions. I was simply questioning the idea that we function as the "mind of the physician." I agree with you completely about collaborating as members of a team.