Nursing Diagnoses

If you are a home care nurse you take lots of verbal orders--we can't put on a band aide or tell a patient to take colace or tylenol without getting an okay from a doctor. (We rarely ever talk to the actual doctor though, it is the doctor's nurse or medical assistant who gives us the orders.) Each home care agency has a very specific policy on how the orders have to be written.

Where I worked before it was pretty straight forward. Patient has a headache, asks me if it is okay to take Tylenol. Tylenol isn't on patient's official med list. After confirming with the patient that he or she doesn't have liver problems, I call patient's doctor and talk to the nurse at the office. "Hey, Mrs. White has a headache, is it okay with Dr. Smith if she takes Tylenol for it?"
Nurse replies, "Oh, yes, that is fine."

So I write my order. "Patient to take tylenol 325 to 650 mg every 4 to 6 hrs by mouth, as needed for headache. Not to exceed 3000 mg in 24 hour period. Order effective 5/14/10." I sign it and put it in the bin to be faxed to Dr. Smith for his signature and tell my patient she can take tylenol as needed for her headache, as long as she doesn't overdose on it.

Or if one of my patients were to fall I would call the doctor's office and get an okay to send out a physical therapist. I would write an order that simply said, "Physical therapist to eval and treat patient for instability and gait disturbances. Order effective week of May 17, 2010".

Where I currently work, writing an order is a major headache, and I find myself poring out a long list of official nursing diagnoses trying to figure out how to write my order. The order has to include a problem, which is supposed to worded as an official nursing diagnoses, an intervention (what you are going to do, like tell the patient to take tylenol), and an achievable goal (Pt will be relieved of headache).

Nursing diagnoses are kind of like a secret code that nurses communicate in. An example of one, if a patient's problems are mostly related to being overweight, we would give him the diagnoses of "Altered nutrition, greater then body requirements" instead of saying that he is obese. For a list of official nursing diagnoses, click here.

An order I have written several times using this format is one where a patient is taking medication to prevent blood clots and needs frequent lab draws to monitor the effectiveness of the therapy:

Problem: Ineffective anticoagulation therapy.
Intervention: Skilled nurse to draw PT/INR in one week. Results to be called to Dr. Smith.
Goal: Labs will be within therapeutic range.

Today I was talking to a sweet elderly patient who is currently living with her grandson and his wife. She reluctantly confided to me, that she feels like they think she is a burden to them, even though she is pretty independent. She feels like they have been cold to her and are ignoring her most of the time and thinks they want her out of the house, even though she says they would never say that out right. I asked if she would be interested in talking to a social worker to explore the options for assisted living or other types of appropriate housing.

She said yes, and looked very relieved that there might be some hope for getting her own place. I called the doctor office and spoke with the nurse. Our conversation was literally:

Me: Hi, this is Kateri, one of the RN's at (insert agency name). I'm calling to see if it is okay with Dr. Jone's if I send out one of our social worker to talk to Anne Brown about options for assisted living."
Nurse: "Oh, that sounds great. Go ahead and do it."
Me: "Thanks so much. I will write up the order and we will fax it to for Dr. Jones to sign. Can you give me your name?"
"It"s Debbie."
"Thanks so much, Debbie."

Great. I have my order. Except now I have to figure out a nursing diagnoses that fits the problem of "my family seems like they are sick of having me around." (Especially since there doesn't seem to be one that fits "I'd like to move into assisted living.")

Hmmm...how about...

Caregiver role strain? That doesn't seem right.
Risk for caregiver role strain? No not that one either.

Compromised family coping?
Readiness for enhanced family coping? Don't think I will go with either of those.

Dysfunctional family processes? That sounds a little harsh. And I'm not sure that the family is really dysfunctional.

How about something not related to to family or caregivers, such as...

Readiness for enhanced decision making? Okay that sounds really pompous.

Risk for compromised human dignity? No...

I like this one: Readiness for enhanced power.
But I'm sure if I use that one, the doctor will take one look at it and think, what the heck is this nurse talking about?

I finally give up on nursing diagnoses and write my order in plain English:

Problem: Patient states she would like to explore options for assisted living.
Intervention: MSW to eval for alternative housing and other community resources.
Goal: Pt will find a living arrangement that meets her needs.

(For some reason you don't have to put the effective date on orders for this agency. The effective date was the huge sticking point for the company I worked for previously.)

If my supervisor wants to scrap my order and rewrite it the proper way with proper nursing diagnoses, that is fine with me. I would just really like to know which one she decides on.

(Names and circumstances changed to protect patient privacy.)