Yeah, Right, Nurses Don’t Diagnose

I learned today that I can’t diagnose death. Death is a medical condition and therefore can be diagnosed only by a physician, or some such silliness. Technically, then, I can report to a doctor that the patient lacks vital signs, and then the physician can deduce the death diagnosis, but that still rings hollow with me since the death certificate reads the time I pronounce the patient—dead, not experiencing a lack of vital signs.

This is on the sillier side of the diagnosis shenanigans in medicine, but it also shows how flawed this system is. Nurses diagnose. It’s a fact. I’m not talking about the specially made NANDA nursing diagnoses (also flawed; what does "ineffective denial" even mean?), but about your everyday conditions. We don’t tell patients what we think, we don’t write in our assessments what we think, but we almost always have a diagnosis or two floating around in our heads.

Why? Because diagnosing is an organizational process. It helps us organize our assessments, treatments, and care. In the ER, I learned that triage nurses are ace diagnosticians. This patient has a kidney stone, the patient says he has back pain but I think it’s a triple-A, this lady has vertigo, that kid has croup…. Nurses of all specialties diagnose and work backward from it to anticipate what the provider is going to want to know to arrive at (or disprove) the same thing.

For example, say your patient suddenly has decreasing oxygen saturation and difficulty breathing. NANDA would stop there with "ineffective ventilation" or some such. In reality, the nurse will know, with decent reliability, whether this person is in heart failure, is having a transfusion reaction (TRALI), has a collapsed lung, or has a pulmonary embolism. The response to the condition, of necessity, depends on a solid theory about the end game, otherwise known as "diagnosis." It is this diagnosing done by nurses that allows us to, respectively, have the Lasix ready, prepare for intubation, have a chest tube tray out, or have the CT scanner on standby already by the time a physician is able to respond. "Ineffective ventilation" won’t get anyone very far other than to re-state the obvious ("the patient is having trouble breathing").

Even in nonemergent situations, we are pretty sure what is wrong with you, and we will help you out by getting physicians what they need to determine it. If you come in limping on your right foot and have a fever and abdominal pain, you probably have appendicitis. We’ll have your blood and urine sent and anticipate a CT scan before you ever see the doctor. If you’re blue, you’re probably in DIC. We will be standing by with the heparin, ready to go.

In fact, I’ll just come out and make a startling claim here: I feel confident that I know when a person is dead or not. Should nurses be able to chart that they think someone has a stage IV retinoblastoma? No. I just think it’s time everyone admitted that nurses diagnose things all the time. I would say it’s time to get rid of NANDA diagnoses, but that time was decades ago already!

About Megen Duffy

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Megen Duffy, RN, BA, BSN, CEN, is a practicing nurse, blogger, and contributing editor for the American Journal of Nursing. Megen has practiced in a variety of settings from emergency rooms to prisons.