Nurses diagnose, too

I OFTEN get bombarded with a seemingly redundant but nonetheless frequently asked question (FAQ) coming from students, professionals and the laity as to whether nurses are legitimate to diagnose.

Before I answer the FAQ, allow me to present several theoretical propositions first that are applicable to the issue at hand.

Diagnosis, as defined by Webster International Dictionary: “[is] the art or act of identifying a disease from its signs and symptoms.”

“A diagnosis is a kind of classification,” writes Dr. Leonard Glick, a medical anthropologist and contributor of Culture, Disease and Healing Studies in Medical Anthropology.

“It contains a diagnostic statement about a condition that declares it to be an illness and assigns it to a particular category of illness,” he adds.

As applied in health professionals’ practice, when a practitioner is diagnosing, he or she is actually classifying the manifestations or signs and symptoms and then grouping them together under a particular category or label that the patient is experiencing. In short, the practitioner is doing a synthesis (putting data together in a new way).

According to one medical article, diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of a phenomenon.

Almost exclusively, the health professional that is associated with diagnosing is the physician.

“A medical diagnosis,” writes Dr. Lois White in her Documentation and the Nursing Process, “is a clinical judgment by the physician that identifies or determines a specific disease, condition or pathologic state.

Dr. Eva Irene Yu-Maglonzo, professor of the University of Santo Thomas faculty of Medicine and Surgery, mentions in her The Filipino Physician Today: A Practical Guide to Holistic Medicine that a medical diagnosis is a clinical reasoning that helps the physician pinpoint the most likely medical problem of the patient.

“Clinical reasoning involves the steps of hypothesis formation, hypothesis refinement and hypothesis confirmation,” Dr. Maglonzo adds.

According to Dr. Maglonzo, during the hypothesis formation stage, the physician initially identifies the possible disease entities of the patient based on the latter’s medical history with emphasis on the chief complaint or the reason why the patient sought consult on the first place.

During the hypothesis refinement, Dr. Maglonzo wrote that the physician narrows down his or her medical considerations by the use of such words as “probably,” “unlikely” or “certain” to describe the likelihood of a diagnosis.

“Pertinent positive or negative signs and symptoms can help rule out a disease entity,” she writes.

Lastly, during the hypothesis confirmation, Dr. Maglonzo wrote that after a thorough analysis, the physician confirms diagnosis based on a gold standard which is anchored on evidence rooted in diagnostic or laboratory tests.

Going back to the question “Do nurses diagnose?”

The answer is yes.

As a matter of fact, the NANDA International (formerly, the North American Nursing Diagnosis Association), a professional organization of nurses that standardized nursing terminology since its creation in 1982, has set the working definition of nursing diagnosis as “a clinical judgment about the individual, family, or community responses to actual and potential health problems and life processes.

In the Philippines, practicing nurses have adopted the criteria set by the NANDA International. However, in nursing practice, a ‘nursing’ diagnosis differs from the medical diagnosis of the physician.

A medical diagnosis focuses on pathologic processes. As Dr. Maglonzo sites in her book, the pathologic processes may be mechanical (as in cases of musculoskeletal trauma), inflammatory (as in cases of pericarditis or inflammation of a layer of the heart) or infectious (like pneumonia).

On the other hand, a nursing diagnosis, as emphasized by Dr. White, focuses on a client’s response to health and it provides a structure to which nursing care can be delivered.

An example of a nursing diagnosis is ineffective airway clearance as evidenced by productive cough.

Another difference lies in the client or entities that are being taken care of. In medical diagnosis, the label is only applicable to the patient being diagnosed (example a patient has diabetes or myocardial infarction). In nursing diagnosis, however, the diagnostic statement can extend into the family or community as a whole. In fact, in nursing, we have family and community health diagnosis.

While nursing diagnosis is entirely different, it follows the same problem-solving approach of the medical diagnosis.

A patient has both medical and nursing diagnosis. For example, the patient may have been medically diagnosed by the physician with congestive heart failure. The nursing diagnosis applicable could be “decreased cardiac output” or “deficient knowledge regarding disease process.

So what benefits can be gained of nursing diagnosis?

“The use of nursing diagnosis provides nurses with a common language for identifying client needs, aids in the choice of nursing interventions and provides guidance for evaluation,” states Dr. Marilynn Doenges, a nurse scientist and co-author of Nurse’s Pocket Guide: Diagnoses, Interventions and Rationales.

Another benefit is that nursing practice approaches a more scientific or evidence-based practice because every nursing diagnosis has accompanying prescribed nursing interventions (or what the nurse is expected to do to the patient) that is based on research; not just random interventions.

For example, if the patient receives the nursing diagnosis “risk for infection,” the nurse may intervene by instituting measures to prevent infection at the patient’s, nurse’s and environmental levels.

But there are problems with the nursing diagnosis. For one, it is highly generic. Unlike the medical diagnosis that can further undergo a differential diagnosis, a nursing diagnosis is a terminal or end point diagnosis that cannot be further differentiated; it can only be changed depending on the patient’s response.

Second and it’s very unfortunate, there are Filipino professional nurses who also get confused between a medical and nursing diagnoses. In fact, one sociological survey revealed that a good number of nurses could not distinguish correctly the difference between the two.

Another striking result of the study is that the longer the nurse has been practicing in the country, the more their usage of nursing diagnosis is diminished embracing only the medical diagnosis approach of the patient; a paradox, in a way.

Professional nurses should practice nursing diagnosis regularly. It helps define professional practice. Deliberate failure to do so is like not fully practicing the profession that the nurse has been licensed for.

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