Truth about Nursing diagnosis

magicman · Oct 21, 2004

Many interesting posts on this thread. Thought I'd toss my 2 cents into the mix here too. :)

As a nurse who started as a paramedic, I have a differnt outlook on nursing as a whole as compared to many I have spoken with who came thru only nursing school. The largest difference is that paramedics are accepted easily by physicians and nurses are not (no flames or discussion of doctor/nurse relations please).

With that said, let me put a thought out to all of you. Nursing "diagnoses" are just a long handed way of writing a medical diagnosis. It's the SAME thing people!! "Inadequate airway exchange r/t fluid volume overload" is a LONG way of saying CHF. It's the definition of it!! I thought nurses were supposed to have their own "unique" body of knowlege? This "body of knowlege" is NOT unique, it's a round about way of saying the same thing as a medical diagnosis without actually saying those words (because they're sacred???).

As many have said, ND are a great tool in school to get you thinking along a certain line with patients. In the real world, is there REALLY a point to them? A few have mentioned they are useful when you don't know anything about the patient. Well, I pose this answer to them. Read the progress notes, MAR, I/O sheet and labs, and I'll bet 10:1 you have a GREAT picture of the patient without even GETTING to the CP.

AFA nursing as a profession, I agree whole heartedly that we are. But why must we, as a profession, have to PROVE our knowlege and abilities through so mush truly useless paperwork? The paper doesn't make the profession. Our ACTIONS do. Our abilities to care for and treat our patients appropriately. To make accurate assessments of them and impart this information to the physician in a timely, accurate, and succint way. That is professionalism. To call the physician at 3 AM and say "Mr. Jones is getting short of breath." with no set of v/s, intake and output, description of how he looks, an SaO2 (maybe even a blood gass if the area you're working in is appropriate for that), maybe an EKG, etc. and telling him (the physician) you placed Mr. Jones on O2 @ 2lmp (or whatever may be appropriate) and how it helped, and what else you'd like to do (either as a suggestion or directly asking for it depeneding on the physician), is only ASKING the physician to look down on you (and in turn other nurses) and NOT think of us as professionals. Basically, if you ACT like a fool, you'll damn sure be treated as one by the medical community. You want to be treated as a professional? Then ACT like one. Nursing is no longer subservient to medicine. We are a part of the team. Patients don't come to the hospital to see a physician, they come to see nurses. We are given an education in nursing school, USE it for heaven's sake.

Sorry for the rambling. Guess I got carried away there. :rolleyes:

As to ND's being research based and helpful in developing evidnce based practice, I agree in theory. Research is great in teaching hospitals, and multi center studies, but in daily practice, with the current state of healthcare (short staffing, high patient loads, etc.) they (ND's) take more time than they're worth. As to having a "language" for our profession and setting us apart as a profession, why? Why make it SO obscure that even physicians don't (and won't) read it? Hell, even WE don't understand and use them how they were meant!! We fill in the blanks and change them as we need because it's a requirement. The medical community uses their education (which is basically taken for granted they KNOW what they're doing) to write out what they see and plan for us to do (yes, THEY plan what will be done for the patient in a broad sense), then we carry it out. Why can't WE do the same? Why MUST we write out in LONG HAND what we're going to do, and THEN go do it? Why not just go DO it and write what you did? I mean, if someone is dyspneic lying supine, do we not put them in a fowlers position (if that's appropriate for the patient's condition)? We don't write "will maitain HOB at 45 degrees to facilitate better oxygenation", we write HOB placed in fowlers with decrease in SOB (or something similar). And if we don't, won't the physician either do it himself or TELL us to (reposition the pt.)? What in that is nursing specific (other than nurse are the ones who DO it)? C'mon y'all. Stop deluding yourselves and your fellow nurses into believing we have a separate language and "specific body of knowlege". Our "body of knowlege" is based in MEDICAL evidence (prove me wrong here). Yes, it is considered nursing care, but it's said to be "medically appropriate", not "nursingly appropriate".

Katmae RN · Oct 21, 2004

Hi candicane..i read your post and immediately thought of University Hospital. It seems when you work at a University hospital the literary genious' have to justify their salaries with added work for the floor nurses. It gives them something to justify why they are employed there. Imagine how many bedside nurses could be hired with just one of their salaries.

Katmae RN · Oct 21, 2004

LMAO very well said! I love the call security part hahahahaa

Drysolong · Oct 21, 2004

You will find out that you will have to forget most of what nursing school teaches you, if you hope to function in the real world of healthcare. That is, unless you plan to spend your entire career in academia, which is the only place you will need nursing diagnosis and goals.
When I first started school, an instructor was giving one of our first lectures on goals. She said that a nurse begins her day by asking her client what goals he or she would like to work on that day. I rolled my eyes, and told the instructor that if I were a patient in the hospital, and a nurse came into my room calling me her client and asking what goals I wanted to work on that day, I would call security.
Later on, another teacher, someone a bit more in touch with reality, told us that the only goal a patient has is to get the hell out of the hospital in one piece.

:rotfl: This post made me laugh out loud. Rather embarassing, since I am in the Computer Lab at school.

vortex72 · Oct 23, 2004

Magicman, you must be a guy cuz us guy RN's are short and to the point :)

No flaming intended but I always find it funny listening to 2 guys giving "report" vs 2 women. The guys will say "Mr. Jones has (diagnosis) and (access), moderately unstable, Has dopamine prn.. any questions?"

Woman report, "Oh his family is so upset and they have this sister that wont leave at visiting time and Mr. Jones likes to keep the TV on the Travel Channel'

lol

On the topic of Nursing diagnosis. I GUESS they might be helpful in school, but beyond that they are freakin' joke.

My favorite nursing Diagnosis was "Energy Field Disturbance" Haha tell the attending MD you've "diagnosed" the patient with that and see what happens!

magicman · Oct 23, 2004

Magicman, you must be a guy cuz us guy RN's are short and to the point :)
No flaming intended but I always find it funny listening to 2 guys giving "report" vs 2 women. The guys will say "Mr. Jones has (diagnosis) and (access), moderately unstable, Has dopamine prn.. any questions?"
Woman report, "Oh his family is so upset and they have this sister that wont leave at visiting time and Mr. Jones likes to keep the TV on the Travel Channel'
lol

Hahahaha.........yeah, I'm a male nurse also. Strangely, I've observed the same thing, even in the E.D. (where I currently work).

On the topic of Nursing diagnosis. I GUESS they might be helpful in school, but beyond that they are freakin' joke.
My favorite nursing Diagnosis was "Energy Field Disturbance" Haha tell the attending MD you've "diagnosed" the patient with that and see what happens!

I GOTTA get a copy of the current NANDA list and see this one!! I can just imagine telling this to one of the docs I work with. Any one of them would look at me as if I had been into the Pyxis for personal satisfaction!! Hahahahahaha

ChezzaRN · Oct 23, 2004

I have to be honest, they really helped me focus in on different medical diagnosis within my scope of practice and focus on what my interventions would/could be for the sole benefit of the patient. Take alteration in cardiac output, it relates to the three basic things a heart can do/not do, pump failure, change in electrical conductivity, and mechanical failure. You get an admission (or report) medical diagnosis, CHF, for example, and then assess the patient and proceed to do what we are allowed to do in the scope of nursing practice, ie: interventions: Give Lasix. We need rationales, why am I giving lasix, what does it do? When DON'T I give the lasix, what is the blood pressure? And so on.... Outcome criteria are the goals for which we see in our patient's future to help them gain maximum activities of their daily life once again(insert here: time to do some investigative work, ask questons about their lives/diet/etc) I digress......lasix will clear the rales out, I placed a foley so I know the exact output and listen to lungs sounds over again. I can see the big picture, not just the fact I walk in and hear I hear rales, now what? It brings professionalism to nursing, you walk into that patient's room knowing your potential interventions, rationales, outcome criteria/potential teaching which COULD start that minute they ask you a question, you have a *plan of care*.....

I haven't been in school for a while so forgive my simplified answer.

I have my AS degree, I have been a nurse for almost 15 years now and this has never left me. I feel blessed to have learned it. Just my two beans for the day. :wink2:

ChezzaRN ICU/CCU

magicman · Oct 23, 2004

I have to be honest, they really helped me focus in on different medical diagnosis within my scope of practice and focus on what my interventions would/could be for the sole benefit of the patient. Take alteration in cardiac output, it relates to the three basic things a heart can do/not do, pump failure, change in electrical conductivity, and mechanical failure. You get an admission (or report) medical diagnosis, CHF, for example, and then assess the patient and proceed to do what we are allowed to do in the scope of nursing practice, ie: interventions: Give Lasix. We need rationales, why am I giving lasix, what does it do? When DON'T I give the lasix, what is the blood pressure? And so on.... Outcome criteria are the goals for which we see in our patient's future to help them gain maximum activities of their daily life once again(insert here: time to do some investigative work, ask questons about their lives/diet/etc) I digress......lasix will clear the rales out, I placed a foley so I know the exact output and listen to lungs sounds over again. I can see the big picture, not just the fact I walk in and hear I hear rales, now what? It brings professionalism to nursing, you walk into that patient's room knowing your potential interventions, rationales, outcome criteria/potential teaching which COULD start that minute they ask you a question, you have a *plan of care*.....
I haven't been in school for a while so forgive my simplified answer.
I have my AS degree, I have been a nurse for almost 15 years now and this has never left me. I feel blessed to have learned it. Just my two beans for the day. :wink2:
ChezzaRN ICU/CCU

One point I gotta bring up with your post is that medication delivery is NOT within the scope of independent nursing practice. It is done only on the express order of a physician, thus nursing can not do it independently and therefore is not part of the nursing process/care. It is medical care. The evaluation of it before and after is part of the nursing process, but also is part of the medical model of care (evaluating the medical care given). As for why you are giving a specific medicine, that again is within the medical care of the patient (remember that nurses can NOT independently TREAT the patient with medications.) Also, contraindications, side effects, etc. are all medically based as well as within the realm of nursing. Therefore they are not exclusive to nursing. My point? Nursing perports to say that ND's and what they do accomplish are exclusive to the profession of nursing, and they are not. True nursing ONLY care is comfort, positioning, EDUCATION (probably the biggest thing we as nurses can do with and for our patients), etc. We (nursing) have delegated MANY skills (said hands on care) to non licensed support personnel (foley placement, bed baths, splinting, morning ADL's, etc. have and ARE all done routinely by CNA's, techs, etc.) so we can "focus" more on the "nursing process (said PAPERWORK). We spend less time at the bedside now than ever before in the name of better patient care and advancement of the nursing profession, yet we forget WHY we are nurses..............the patient. Without that person lying in the bed (or any other place we interact with patients), we have no profession (as it relates to direct patient care in the hospital, ECF, etc.).

ChezzaRN · Oct 24, 2004

One point I gotta bring up with your post is that medication delivery is NOT within the scope of independent nursing practice. It is done only on the express order of a physician, thus nursing can not do it independently and therefore is not part of the nursing process/care. It is medical care
I absolutely agree with you.
I wouldn't (nor haven't) ever given a med without a doctor's order. I failed to include a more succinct detailed account in my answer. Mea Culpa.
The evaluation of it before and after is part of the nursing process, but also is part of the medical model of care (evaluating the medical care given). As for why you are giving a specific medicine, that again is within the medical care of the patient (remember that nurses can NOT independently TREAT the patient with medications.) Also, contraindications, side effects, etc. are all medically based as well as within the realm of nursing. Therefore they are not exclusive to nursing. My point? Nursing perports to say that ND's and what they do accomplish are exclusive to the profession of nursing, and they are not.
True nursing ONLY care is comfort, positioning, EDUCATION (probably the biggest thing we as nurses can do with and for our patients), etc.
~I disagree! Comfort, positioning and education? Come on! And the use of the word *true* is a bit misleading. It's subjective, really. Nursing is an art and a science!
We (nursing) have delegated MANY skills (said hands on care) to non licensed support personnel (foley placement, bed baths, splinting, morning ADL's, etc. have and ARE all done routinely by CNA's, techs, etc.)
~I am not sure what you do or where you work but not in our ICU/CCU, it's primary care. And I don't mind it in the least, even with all the paperwork overload we face. I don't delegate unless absolutely necessary, even when we do have a surprise and have maximum staffing of two techs rather than the usual one in our 20 bed unit. And they are limited to ADL's/blood sugars, I and O's.....I don't "forget why I am a nurse" I simply stated in my post that I am grateful for what I learned about nursing diagnosis to pull a picture together for the total patient care, whatever happens and whatever is diagnosed, the doctor WILL order meds interventions, diagnose and do his job while I carry out mine, but to have the full picture in your head of what potential meds/interventions/ etc is what makes me feel organized to carry out a plan for my patient who is critical. I never said I thought we should focus on the nursing process to drop bedside nursing no way....but it's important, I only have carried what I have learned and added to it through the years.
so we can "focus" more on the "nursing process (said PAPERWORK). We spend less time at the bedside now than ever before in the name of better patient care and advancement of the nursing profession, yet we forget WHY we are nurses..............the patient. Without that person lying in the bed (or any other place we interact with patients), we have no profession (as it relates to direct patient care in the hospital, ECF, etc.).[/quote\
Personally, we spend more time away from the bedside due to corporate measures carried forth by management to bring in big bucks. End of story. The hospital is a business and it's their hokey pokey ideas they come up with for us to implement it's NOT taking out two seconds to mark your initals on a careplan or five seconds to update it as most of us do. Business crap takes nursing away from the bedside, not the usual paperwork, that is the same, nothing has changed there........The nursing process is our basement membrane to take care of a sick patient who needs us, patient is Latin "to suffer" so yes, we do comfort, position and educate, but we do a lot more! I hate limiting such a wonderful profession and hating the very things that are our beginning, jeez louise, no wonder we never get anywhere!
Chezza Forgive spelling and grammar, very tired tonight.....

HappyNurse2005, RN · Oct 24, 2004

I am a nursing student, graduating in May 2005. hence the user name.

anyhoo, we use the Ackely/Ladwig "Nursing Diagnosis Handbook: a Guide to Planning Care". pretty good, i guess.

someone above mentioned the diagnosis Energy Field Disturbance. from my book

NANDA definition: A disruption of the flow of energy surrounding a person's being, which results in a disharmony of mind and spirit

Defining Characteristics: Temperature change (warmth/coolness), visual changes (image/color), disruption of the field (vacant/hold/spike/bulge), movement (wave/spike/tingling/dense/flowing), sounds (tone/word)

personal note-what the heck does that mean? hallucinations?? lol :)

I can see the benefit of making you think critically. i can think critically enough that I can tell what dx a person has just by reading their chart, I dont always need to read the book. Of course, you tend to use the same ones repeatedly. Acute Pain, Impaired Physical Mobility, Risk for Infection.

some of them are just plain weird. Besides the energy field one-Deficient Diversional Activity? is that a fancy way to say the patient is bored? I tried to write a care plan on that once, just to be different. I couldn't do it-I scrapped that idea and went for a more traditional one.

It has taught me to think more critically. I just wonder why they are emphasized (along with the careplans they accompany) so heavily. We have to write numerous careplans, must get a certain amount of them "satisfactory" to pass from one semester to the next, but we get no letter grade for them. They in no way count for our numerical grade. and so much emphasis on these, and then they aren't used in "real world" nursing.

Seems there could be a more relevant way to do this. Of course, I don't know what that way would be

Rose

peaceful · Oct 24, 2004

spent many pointless hrs in nursing school studying nursing dx's. Never have used out in the real world both in the hospital and community nurse setting. Critical thinking skills are required but nursing diagnosis info has never helped me there. Unfortuantely there is tons of bs to nursing school such as group projects required in every class, hundreds of pointless hours spent on these projects, every one is bored out of their minds listening to the groups including the instructors. Once you do it a couple time is enough, but no every dam class requires a group project.

NurseFirst · Oct 24, 2004

Magicman, you must be a guy cuz us guy RN's are short and to the point :)
No flaming intended but I always find it funny listening to 2 guys giving "report" vs 2 women. The guys will say "Mr. Jones has (diagnosis) and (access), moderately unstable, Has dopamine prn.. any questions?"
Woman report, "Oh his family is so upset and they have this sister that wont leave at visiting time and Mr. Jones likes to keep the TV on the Travel Channel'
lol

hmmm...perhaps you two guy RNs missed the part about nursing also being concerned with psycho-social issues, which the comments you have quoted would be directly related to. That is ONE thing which is quite a bit different between "medical" and "nursing" models.

As far as PMs being more respected by docs than RNs--not sure how or why you come to that conclusion, but, if true, I think it has a lot more to do with the predominant sex in each profession (and also the history of each) than the expertise. Sexism is quite alive and well, in healthcare as well as other human endeavors--such as corporate environments.

As far as NDs and NCPs are concerned -- I agree, I HATE doing them. However, I have found that some books, such as the Ackley and Ladwig book, are helpful in expanding my repertoire (sp?) of nursing interventions for various patient problems. Granted, I am still a student, but we've already covered some of the areas in theory where I've done nursing plans and have found interventions not discussed in our theory classes.

NurseFirst