Using "Medical" terms

[Episteme]

I would like to ask students how/if they have been instructed to use "medical diagnosis" in formulating their care plans.

Medical and nursing diagnoses are two very different things. The whole thrust of the nursing process is wrapped around the whole person, family, community and restoring it/them to their best health. Medical diagnosis defines the disease. Nursing looks at health and deviations from it. Docs look at illness. Medicine has a narrow frame of reference, nursing an incredibly broad one.

But, in some circles, students are not allowed to use "COPD" or "stroke" or "Pancreatitis" anywhere in their care plans. I have had instructors tell me my students couldn't put "Anemia" or "Dehydration" in their assessment data as descriptors because these are "medical" terms.

I would like to know what you've been told (while a student) to do with medical terms when you articulate/write/discuss your plan of care.

Thanks.

[smf0903]

We were told never to use a medical diagnosis in our plans. However, we were told we could use "secondary to..." In our plans ("fatigue, secondary to anemia"...that type of thing) However, we still try to avoid doing that. A medical dx term seems to stick out like a sore thumb LOL

Edited to add: As far as what you mentioned about assessment data (I'll use the "fatigue, secondary to anemia" example), we are not allowed to use medical diagnoses in the data. The labs would explain the anemia (low H&H, iron, etc) and that's how we were taught to put the data in that backs up both without putting a medical diagnosis in the assessment data.

[RunBabyRN]

We were told never to use a medical diagnosis in our plans. However, we were told we could use "secondary to..." In our plans ("fatigue, secondary to anemia"...that type of thing) However, we still try to avoid doing that. A medical dx term seems to stick out like a sore thumb LOL

Edited to add: As far as what you mentioned about assessment data (I'll use the "fatigue, secondary to anemia" example), we are not allowed to use medical diagnoses in the data. The labs would explain the anemia (low H&H, iron, etc) and that's how we were taught to put the data in that backs up both without putting a medical diagnosis in the assessment data.

This. We can use a medical diagnosis as a "secondary to" for something, as some nursing diagnoses ARE r/t the medical diagnosis, but most nursing diagnoses are not, and this is where our instructor taught us to look at the WHOLE patient, not just the admitting diagnosis. How are they coping? Are there any risks associated with what's going on? Any issues related to their care thus far? Ie they were confused and pulled out their Foley, anything going on there? Pain? Problems with urination? Potential risk for sexual dysfunction? Embarrassment?

[Episteme]

RunBaby and smf0903,

What you say seems reasonable to me. Would you be allowed in your assessment data to write "2nd admission in 3 mos. for respiratory failure." Or "diagnosed 2 years ago with metastatic breast cancer."

[Compassion_x]

Well, we can say "fluid volume deficiency," instead of dehydration. There are ways around using medical diagnoses. On the other hand, isn't "constipation" an actual nursing diagnosis? I don't think I've ever actually used it so I don't remember. But I had an instructor tell us not to use it. But if it is a nursing diagnosis????? What.

We are not allowed to use medical diagnoses in the R/T part. No impaired gas exchange r/t pneumonia sort of stuff. Or in assessment data we can't just put "pneumonia" but what s/sx they're actually showing as we cannot give medical diagnoses. I feel like some of that is actually proving we have medical/nursing knowledge beyond reading a chart, at least in school.

[classicdame, MSN, EdD]

It comes down to documenting what you can do something about. The idea is to get the nurse to focus on a nursing intervention. So I can focus on ineffective gas exchange as evidenced by O2 sats

[LoriRNCM, ADN, ASN, RN]

Isn't FVD (hypovolemia) different than dehydration anyway though? Sorry, that caught my attention. In FVD you have electrolyte loss (hyponatremia/hypokalemia). In dehydration you may have hypernatremia. Or did I learn nothing last semester? Lol

[akulahawkRN, ADN, RN, EMT-P]

Isn't FVD (hypovolemia) different than dehydration anyway though? Sorry, that caught my attention. In FVD you have electrolyte loss (hyponatremia/hypokalemia). In dehydration you may have hypernatremia. Or did I learn nothing last semester? Lol

Fluid Volume Deficit and hypovolemia both refer to the patient being "dry." Both can have electrolyte imbalances but I think that FVD is more "global" in that it also can refer to total body water across all body fluid compartments whereas hypovolemia is probably more specific to the vascular compartment.

[AZirish]

We were told never to use a medical diagnosis in our plans. However, we were told we could use "secondary to..." In our plans ("fatigue, secondary to anemia"...that type of thing) However, we still try to avoid doing that. A medical dx term seems to stick out like a sore thumb LOL

Edited to add: As far as what you mentioned about assessment data (I'll use the "fatigue, secondary to anemia" example), we are not allowed to use medical diagnoses in the data. The labs would explain the anemia (low H&H, iron, etc) and that's how we were taught to put the data in that backs up both without putting a medical diagnosis in the assessment data.

Yes, this is ours as well, we are not allowed to use medical terms in our assessment date.... only in the "secondary to" of the nursing diagnosis.

[smf0903]

RunBaby and smf0903,

What you say seems reasonable to me. Would you be allowed in your assessment data to write "2nd admission in 3 mos. for respiratory failure." Or "diagnosed 2 years ago with metastatic breast cancer."

Yes, we're allowed to put those things in the assessment data because many times they are important to the overall picture. I always word it as "Hx of X, Y, Z". The current medical dx I don't put in there (unless, like I said above, as "secondary to"), but I think the pt's Hx is many times important for the current NURSING dx...does that make any sense? (I'm studying for finals so I probably sound like I'm talking out my big left toe LOL)

[ellaballet]

I've been told the same thing as many of the other replies - we can use it in the r/t part of the diagnosis. My teacher encourages us to use "Impaired gas exchanged related to disease process" instead of "related to COPD" though.

[Everline]

We are not allowed to use any medical diagnoses in our care plans. This was told to us early on, so I avoid it even when it seems like it would add to the care plan or to the overall picture of what is happening with the patient.