This may make me look silly..

[carys]

I'm not a nursing student yet.. pre nursing student. Since I am on break from the semester, I am bored and have been doing a lot of reading on here. There are some things I don't understand. Maybe I am getting too far ahead of myself, but it's all out of curiosity for now.

Assessments...

When I was in mother baby as a patient, no one looked in my eyes with a pen light. So do particular units do assessments or what? When do you do an assessment? On admission?

Also, if we have a medical diagnosis, why do we need a nursing diagnosis?

[Nola009]

Nurses on a specialty (or even general) unit will do a focus assessment, unless a complete head to toe is warranted. A nursing diagnosis is to get you thinking critically and help you ascertain what YOU can do, or what assessment findings you might call the doctor about.

[Been there,done that, ASN, RN]

No one checked your pupils, because your neurological status was not a diagnosis or a problem.

Pupils are evaluated as part of a complete neuro exam.

Nursing diagnosis is completely separate from medical diagnoses. It is what makes us professionals in our own right.

A nursing diagnosis identifies a patient problem present at time of assessment. It is part of the nursing process so that we can then formulate a nursing intervention.

Good luck in your studies, think you will have good critical thinking skills.

[BSNbeauty, BSN, RN]

I'm a mother/baby nurse and we do more of a focused assessment. We normally listen to heart, lung and bowel sounds. Check fundus, lochia, breast, bowel and bladder ( episiotomies, hemorrhoids and etc), swelling in lower extremities.... and ofcourse pain.

When I worked in CVICU we did a full and very thorough head to toe assessment that included the use of the pen light.

When I worked in the ED, it was a focused assessment. I didn't listen to heart and lungs and bowels for a splinter or cut on the hand.

These are just examples of how different specialties require different assessments.

[HouTx, BSN, MSN, EdD]

Good questions. The PPs have already explained about the difference between 'focused' and 'general' assessments.

Nursing has a different scope of practice than medicine. RYI, In the USA, Physicians are the ONLY people authorized to practice medicine independently. Medical Diagnoses are categorized by diseases and illness. Mid-levels (NPs & PAs) have an expanded roles that include some medical tasks, but they must refer to a physician when anything exceeds their scopes of practice.

Medical scope of practice is focused on treatment (cure) of the disease or illness. Nursing is focused on human reactions to the disease or illness. So, a physician may treat asthma with medications, ventilation therapy and oxygen supplement.

Nursing includes both "independent" and "interdependent" (physician delegated) responsibilities and we function from a holistic framework that includes that body, mind (emotions) and spirit. Nursing diagnoses would focus on independent realm such as the reactions (including cellular) and physical, emotional and spiritual needs of a patient with asthma. The nurse would make sure that the patient was fully informed about the disease (knowledge deficit), medications and all facets of treatment. He would also help make sure that the patient's post discharge care is appropriate. Nursing care would include assessing and monitoring for problems with oxygenation and administering medications that the physician has ordered.

Clear as mud??

[Esme12, ASN, BSN, RN]

A nursing diagnosis is all about the patient and what the patient NEEDS! It leads us to know what to do for that patient and keep everyone on the same page. IN school it is s recipe card that is teaching you how to think like a nurse, what to look for in the patient with a specific diagnosis, what you should take care of first , and what those nursing interventions should be.

[carys]

Thank you all! Definitely clear as Mud