Truth about Nursing diagnosis

Ross1 · Oct 24, 2004

All really great points here and I'll admit, when I first read magicman's posting, I had not looked at his username but I just assumed that it was written by a male. Of course we are making broadsweeping generalizations here and not everyone fits this rules, but we all know that it tends to be the case that men are more concrete/task oriented and women are more process/emotion oriented. No flames please....as I said...these are just gross overgeneralizations, however, if there weren't any truth to this, someone wouldn't be making millions on "Men are from mars, women are from venus."

In my own health care practice, I am extremely psycho-socially oriented, however, I present my findings in a very succinct, task/problem solving oriented manner. I have consistently received positive feedback from both male and female colleagues regarding my report style that is business like yet includes all the relevant psycho-social data.

As to the original topic: Nursing Diagnoses.......I have mixed feelings about them. I very much agree that they are a great learning tool for students. Many things that we do in school do help us once we become professionals even if we never do them again. That said, my first reaction to NSG DX on my first day of learning about them in NSG 101 was that they are mainly B.S. Why? They appear to be just a way to qualify a medical diagnosis. It is the medical diagnoses that drive the overall treatment plan and anyone that believes that the use of NSG DX will influence other health care professionals to view nurses as more professional is surely misguided.

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

magicman · Oct 24, 2004

Just HAD to respond to this one.

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!
Notice I added an "etc." in there. I didn't feel the need to go into ALL the details of what we all do. I thought we already knew that part. But I would be interested in what you feel IS truly only in the realm of nursing to perfrom? And what science is nursing based on that is not driven by the medical model?
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.
Unit specifics asside, nursing HAS delegated much of the nursing care traditionally performed by nurses away. Today's nursing students are taught that bed baths, ambulation, ADL's, etc. are not their duties to perfrom. Now, some schools may still teach this to nurses, but many newer nurses I speak with tell me they are taught these are jobs for the PCT's, CNA's, etc.
AFA using CP's to get a picture of the patient, it may be one more tool for nursing, but what other discipline even reads it? Physicians certainly don't, and I don't know one other that does. As I said, even WE (nursing in general) don't use them properly. And we continue to push it as "our" language. Just one more way nursing (again in GENERAL) isolates itself from the rest of the healthcare team in an attempt to justify the position.
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.....
First, who said I hate the things that are our beginning? (and please keep in mind that Ms. Nightingale felt nursing WAS subservient to medicine and should stand when the doctor entered, give up their chair to the doctor, etc.)
Second (and maybe more importantly), what "corporate measures" do you speak of and which management do you mean? Remember, each and every hospital has a DON (CNO, or whatever set of initials your facility uses these days). Ths DON is a nurse, and is supposed to be a nurse FIRST. That would mean being the advocate for nursing within the facility/corporation, etc. If nursing management chooses to aquiesce to the "business" of health care, how does that benefit anyone? (and TRUST ME, I understand that healthcare IS a business today. The only difference between it and the "traditional" business world is the amount of money/incentive available to the workforce)
AFA the paperwork, if yours hasn't changed, then what corporate measures are you speaking of and how are they carried out? Are you telling me/us that the amount of paperwork (or computer work) that is related to your care HASN'T increased over the last 20 years? I know MINE sure has. We document more care on more paperwork in more ways now than EVER before in my 20+ years. Separate pieces of paper for all KINDS of different things that have come about for HMO's and the lawyers (please don't digress to THAT problem in health care here. That is for a thread all by itself).
Now as to the CP's/ND's, as cited before (and I looked it up and it really IS a ND), when is the last time YOU used "energy field disturbance" in a CP? And I certainly hope you're using "coping skills, ineffective, potential for" in EVERY CP written/updated. EVERY patient has this, and we should be prepared to deal with it. My point is there are SO many ND's that fit ALL patients that to do a true total CP (which, at least in the beginning IS the point) can and does take more time than it's worth since no one other than nurses read it (and WE {said nursing in general} use generic CP's with computer generated statements, etc. to save time). If a CP is to be COMPLETE for a patient, it normally should be 10+ or more pages (especially in a critical care area). And for who? Other nurses to be able to read "our language"? No one else even LOOKS at it for anything dealing with the care of the patient. RT, PT, OT, etc. don't even GO to that part of the chart to get a picture of the patient. THEY read the physician's notes, labs, etc. and then talk to the nurse (maybe) and then go talk to the patient. What in the CP gives one a better picture of where the patient is in his/her continuum of illness that isn't in the rest of the chart (except the psych social issues which is where NURSING is the ONLY discipline in healthcare that documents and manages it -- NOT A BAD THING, only stating a point. Someone NEEDS to manage it for the patient, and why NOT nursing? It is a NEEDED part of the care).
As for nursing not being able to get anywhere, I agree totally!! We (said nursing IN GENERAL) spends more time infighting about useless issues (RN v. LPN, ADN v. BSN, advanced practice, ND's {energy field disturbance -- how much time, effort and money was waste on THIS one!?!?!?!}, etc.).
In the end (IMHO) CP's can be a great tool if used properly. Unfortunately, nursing (again on the whole) chooses to use it as a tool to isolate itself from the rest of the team, for the "advancement of the profession".

Marie_LPN, RN, LPN, RN · Oct 24, 2004

A lot of the old-school nurses on the med-surg floors still do this.

And i'll tell you, it me HELPED BIG TIME to see what they had come up with and written. It gave me great info on what i should do for my assignments, and was an excellent learning resource.

magicman · Oct 24, 2004

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.

I didn't miss it, I actually stated it! That's the only place we (nursing in general) are on our own (in general). My point is about CP's though. More emphasis is placed on them from a medical aspect (i.e. "airway clearance, ineffective" -- what's psycho social about THAT?) and more obscure wording used to clarify the MEDICAL diagnosis than anything else.

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 I originally stated, that is not my point in bringing this up. I only did it as a background on where I came from (again, the digression v. to the point of the female v. male - NOT BAD, just different perspectives/ways of interacting).

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

Which has been and still IS my point about CP's!! They are a GREAT TOOL in school to give you a better perspective on patient care!! They give you different ways of looking at a medical diagnosis and what you, as a nurse, can do to help the patient cope with it (without going into the medical aspects of the care). But if we are all supposed to have this basic footing when we enter the workforce, then why why why why why must we continue to write it??? We're only writing it for ourselves (other nurses) and we already know it! You can know what ND's the patient has by reading the physician and nursing notes (the psycho social issues should be documented in the nursing notes), so you already know what's going on. Why RE write these again in the CP? And why write out all the interventions you MAY do for the medical care of the patient? You know you're going to document I and O's, limit fluid intake, limit activity, keep the HOB elevated, etc. for patients with CHF (oops, I should say fluid volume, excessive, R/T altered cardiac output). Why are we writing it out? This SHOULD be a given (unless of course, we don't feel nursing is a profession but more a task oriented job).

magicman · Oct 24, 2004

All really great points here and I'll admit, when I first read magicman's posting, I had not looked at his username but I just assumed that it was written by a male. Of course we are making broadsweeping generalizations here and not everyone fits this rules, but we all know that it tends to be the case that men are more concrete/task oriented and women are more process/emotion oriented. No flames please....as I said...these are just gross overgeneralizations, however, if there weren't any truth to this, someone wouldn't be making millions on "Men are from mars, women are from venus."
In my own health care practice, I am extremely psycho-socially oriented, however, I present my findings in a very succinct, task/problem solving oriented manner. I have consistently received positive feedback from both male and female colleagues regarding my report style that is business like yet includes all the relevant psycho-social data.
As to the original topic: Nursing Diagnoses.......I have mixed feelings about them. I very much agree that they are a great learning tool for students. Many things that we do in school do help us once we become professionals even if we never do them again. That said, my first reaction to NSG DX on my first day of learning about them in NSG 101 was that they are mainly B.S. Why? They appear to be just a way to qualify a medical diagnosis. It is the medical diagnoses that drive the overall treatment plan and anyone that believes that the use of NSG DX will influence other health care professionals to view nurses as more professional is surely misguided.

Very well stated and I must agree 100%!!! That might have been a better way to state my thoughts. Thank you!! :)

been there · Oct 28, 2004

Nursing diagnosis is one of the silliest things I have seen come down the pike. They were invented by nurses who had worked themselves "up the ladder" so far, they had nothing to do but invent more work for those of us who are taking care of patients. They must justify their own jobs by creating paperwork for caregivers. These are the folks that usually end up being JCAHO surveyers!
In other words, they are completely useless. :rotfl:

I'm "up the ladder" as an RN Consultant and I still use nursing diagnoses. Would you take your car to a mechanic who doesn't have any inkling as to what is wrong with your car BASED ON THE SYMPTOMS YOU HAVE TOLD HIM? You create diagnoses based on the patients' subjective and objective symptoms.

How can you honestly think this is "just more paperwork"? As an RN I have had 15 page admit assessment packets to fill out in Home Health. The nursing home MDS is not a "fun project" either. Hospice packets are jammed with forms to fill out. From this information I created diagnoses that were crucial to the health and welfare of each patient and interventions that, as a nurse, I could address. If your facility has extensive paperwork forms maybe a discussion with your supervisor or Quality Assurance department about eliminating paperwork time to give you more patient time is in order. I've been there and I sympathize. JACHO, Medicare, CHAPS, etc., however, won't.

been there · Oct 28, 2004

Nursing diagnosis is one of the silliest things I have seen come down the pike. They were invented by nurses who had worked themselves "up the ladder" so far, they had nothing to do but invent more work for those of us who are taking care of patients. They must justify their own jobs by creating paperwork for caregivers. These are the folks that usually end up being JCAHO surveyers!
In other words, they are completely useless. :rotfl:

I'm "up the ladder" as an RN Consultant and I still use nursing diagnoses. Would you take your car to a mechanic who doesn't have any inkling as to what is wrong with your car BASED ON THE SYMPTOMS YOU HAVE TOLD HIM? You create diagnoses based on the patients' subjective and objective symptoms.

How can you honestly think this is "just more paperwork"? As an RN I have had 15 page admit assessment packets to fill out in Home Health. The nursing home MDS is not a "fun project" either. Hospice packets are jammed with forms to fill out. From this information I created diagnoses that were crucial to the health and welfare of each patient and interventions that, as a nurse, I could address. If your facility has extensive paperwork forms maybe a discussion with your supervisor or Quality Assurance department about eliminating paperwork time to give you more patient time is in order. I've been there and I sympathize. JACHO, Medicare, CHAPS, etc., however, won't.

walnuttree91 · Oct 28, 2004

Nursing diagnosis is one of the most stupid things the profession ever did. If you know the patient's diagnosis, current condition, meds,and history, your care plan should already be in your brain!

walnuttree91 · Oct 28, 2004

Nursing diagnosis is one of the most stupid things the profession ever did. If you know the patient's diagnosis, current condition, meds,and history, your care plan should already be in your brain!

been there · Oct 28, 2004

Nursing diagnoses.....Ahhh. Nursing diagnoses and care plans have their place, but truely...honestly, they are best for students in nursing in assisting them in their critical thinking skills, organization of care, and case management. The truth about nursing school is "we do it this way, but in THE REAL WORLD" as one of my old instructors used to say is very true. It helps you THINK like a nurse. So, in nursing school (learning the trade), I believe they are necessary. Now, in the real world...many institutions have preprinted (canned) nursing care plans/care paths already available to use where all you have to do is tweek it to individualize the care. Nursing diagnosis or terms of observation regarding a patients identified difficulties are again good for the nursing student...but again, in the real world...I can't say that they are honestly being used in any meaningful way. There is great truth that Nursing as a field has tried to make itself "independent" from the doc. This is also true regarding attempts to separate and further define its role away from other professions, such as social work. Much of this push began in the 1980's (am I dating myself?) when the field was tugging at itself from all sides. For example, there has been pushes in different locales to phase out the LPN/LVN. Fool hearty, but hospitals did release a lot of them in the 1980's because they were not an RN (trying to go to an all RN facility). Many of these hospitals had to rehire back these same LPNs because there were not enough RNs. We all have heard about the back and forth push to have all RNs become BSNs, but this failed too because of the same reason. The push you hear now is encouraging nurses to be advanced practiced (which does imply much more independence if you want to call it that). However, in advanced practice, care remains pretty much "supervised" under the doc. Nursing as a field has always had an identity crisis. So, to make a long story short, Nursing diagnosis has been ONE tool of many to help define who we are. Is it practical in the real world? Probably not.

I agree with you totally. We don't use the formal format that we agonizingly learned in school in the real world. We did, however, learn by using the format. I'm upset about this issue because I sense an underlying resentment against learning them in these posts and having them touted as "useless and a waste of time". It is well known that you improve with practice. Our care plans must differ from MD care plans because we take care of the patient in OUR area of expertise. It is no less important than an MD "plan". There are many older experienced nurses in teaching hospitals who have had to inform the MD of what a patient may benefit from, or has had to remind that MD that the patient has had adverse effects from a procedure or medication years ago simply because that MD didn't ask or , as happens in the real world, doesn't spend but a few minutes with a patient. We are the guardians of our patients' health and welfare and we must have the basic knowledge of knowing what should be done because of what is happening to him/her. It is tiring and cumbersome but so is working an extra shift when all hell has broken loose that day. Every facility or organization that hires nurses have different forms and requirements for us. The higher we go in management the more responsible we are for what those we supervise do. For me, I would prefer a nurse who gripes about doing care plans but does them anyway, and with thought added to the process. "Bring toys from home" for children may seem stupid but think about it. I always forgot this intervention in school.

been there · Oct 28, 2004

Nursing diagnoses.....Ahhh. Nursing diagnoses and care plans have their place, but truely...honestly, they are best for students in nursing in assisting them in their critical thinking skills, organization of care, and case management. The truth about nursing school is "we do it this way, but in THE REAL WORLD" as one of my old instructors used to say is very true. It helps you THINK like a nurse. So, in nursing school (learning the trade), I believe they are necessary. Now, in the real world...many institutions have preprinted (canned) nursing care plans/care paths already available to use where all you have to do is tweek it to individualize the care. Nursing diagnosis or terms of observation regarding a patients identified difficulties are again good for the nursing student...but again, in the real world...I can't say that they are honestly being used in any meaningful way. There is great truth that Nursing as a field has tried to make itself "independent" from the doc. This is also true regarding attempts to separate and further define its role away from other professions, such as social work. Much of this push began in the 1980's (am I dating myself?) when the field was tugging at itself from all sides. For example, there has been pushes in different locales to phase out the LPN/LVN. Fool hearty, but hospitals did release a lot of them in the 1980's because they were not an RN (trying to go to an all RN facility). Many of these hospitals had to rehire back these same LPNs because there were not enough RNs. We all have heard about the back and forth push to have all RNs become BSNs, but this failed too because of the same reason. The push you hear now is encouraging nurses to be advanced practiced (which does imply much more independence if you want to call it that). However, in advanced practice, care remains pretty much "supervised" under the doc. Nursing as a field has always had an identity crisis. So, to make a long story short, Nursing diagnosis has been ONE tool of many to help define who we are. Is it practical in the real world? Probably not.

I agree with you totally. We don't use the formal format that we agonizingly learned in school in the real world. We did, however, learn by using the format. I'm upset about this issue because I sense an underlying resentment against learning them in these posts and having them touted as "useless and a waste of time". It is well known that you improve with practice. Our care plans must differ from MD care plans because we take care of the patient in OUR area of expertise. It is no less important than an MD "plan". There are many older experienced nurses in teaching hospitals who have had to inform the MD of what a patient may benefit from, or has had to remind that MD that the patient has had adverse effects from a procedure or medication years ago simply because that MD didn't ask or , as happens in the real world, doesn't spend but a few minutes with a patient. We are the guardians of our patients' health and welfare and we must have the basic knowledge of knowing what should be done because of what is happening to him/her. It is tiring and cumbersome but so is working an extra shift when all hell has broken loose that day. Every facility or organization that hires nurses have different forms and requirements for us. The higher we go in management the more responsible we are for what those we supervise do. For me, I would prefer a nurse who gripes about doing care plans but does them anyway, and with thought added to the process. "Bring toys from home" for children may seem stupid but think about it. I always forgot this intervention in school.

VickyRN, MSN, DNP, RN · Oct 28, 2004

a gentle reminder to keep to the subject at hand and avoid personal attacks. it is perfectly fine to disagree, but do so without attacking on a professional or personal basis.

thank you.

vickyrn

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