Taking Charge of Your Health

As a nurse it is important to understand the
difference between a medical diagnosis, a nursing diagnosis and a collaborative problem.
Nurses have the ability to independently make decisions about nursing diagnoses and collaborative
problems. Medical diagnoses, on the other hand, are made by physicians. A medical diagnosis identifies a specific
disease or condition. In the hospital it is commonly simply referred to as the patient’s
diagnosis. This diagnosis is made by a physician after they assess the patient’s history,
signs and symptoms as well as conduct diagnostic tests as needed. The medical diagnosis will
then be treated by the physician. You can check out the link below for more examples
and information about specific medical diagnoses including signs, symptoms and diagnostic tests. A nursing diagnosis identifies a client’s
response to their health that the nurse can manage. These diagnoses serve as the basis
for the next steps in the nursing process which include planning, intervention and evaluation.
Nursing diagnoses need to fall within the scope of what nurses are licensed to treat
because nurses are accountable for outcomes related to these diagnoses. When the nurse
assesses the patient, they use their clinical judgement to identify specific client problems
and responses that are identified using standardised language from NANDA International. Using this
standardised language is important for communication among nurses. It also has helped to promote
research into client issues that were previously underexplored. A nursing diagnosis handbook
will come in handy as you work through the process of turning your assessment data into
a nursing diagnosis. For a current list of nursing diagnostic labels please see the link
below this video. There are quite a few so we will talk more about how to formulate your
nursing diagnoses in the next video. In short – A medical diagnosis identifies
a disease that the physician treats. A nursing diagnosis identifies an actual or potential
response to a disease or situation that the nurse focuses on. For example, a patient admitted with a medical
diagnosis of breast cancer may have a nursing diagnosis of disturbed body image among others.
The physician would be concerned with treating the medical diagnosis by ordering surgery,
chemotherapy or radiation. The nurse would develop a plan with the patient to help them
deal with any shame, embarrassment or guilt they are experiencing. The term “collaborative problem” is sometimes
used in multiple ways so be sure to clarify what your teacher means if they ask you to
identify or discuss a collaborative problem. A nursing diagnosis may have an intervention
that requires collaboration. For example, to manage acute pain with medication it first
needs to be prescribed. The diagnosis of acute pain is still a nursing diagnosis. Some textbooks
define a collaborative problem as an issue that another discipline has identified that
requires a nursing intervention. This issue would then be placed on the interdisciplinary
care plan. Chances are that if you are asked to write a collaborative problem statement
your teacher is referring to an RC diagnosis. Carpenito’s nursing diagnosis handbook shows
how to place a diagnostic label on complications that nurses cannot treat independently. Carpenito defines Collaborative problems as
potential complications of a client’s condition that a nurse cannot treat independently. They
will probably occur with a specific disease, injury or treatment. Just like the name suggests,
collaborative problems are treated collaboratively by both physicians and nurses working together,
often in collaboration with other health care team members. In your nursing diagnosis handbook
they may be listed under associated nursing diagnoses or in a separate section. Nurses
work to prevent collaborative problems from developing. When collaborative problems exist
nurses have the responsibility to monitor the patient’s status, intervene or get the
physician to intervene when necessary and evaluate how effective interventions are. In short – Nurses cannot treat collaborative
problems independently. They do however monitor for and attempt to prevent these potential
complications. If the nurse can provide the primary treatment for a complication it is
a nursing diagnosis. For example, a patient with a medical diagnosis
of AIDS may have a collaborative problem of being at risk for complications of opportunistic
infections. The nurse can manage and minimize complications related to the patient’s immunodeficiency
but they cannot treat it alone. This same patient may have a nursing diagnosis of imbalanced
nutrition: less than body requirements that the nurse can intervene to manage more independently. I am interested in your thoughts about collaborative
problems. Does your teacher ask you to write Risk for Complication diagnoses? When you
create a care plan do you use collaborative problems? Do you distinguish them from nursing
diagnoses? Do you find collaborative problems confusing? Please tell me what you think. This video is part of a series where I walk
you through how to apply the nursing process. In a subsequent video I will talk about how
to formulate nursing diagnoses. If you haven’t seen the nursing process overview video yet
I recommend that you watch it now. If you aren’t already subscribed you can subscribe
to be notified when the next video in this series comes out. Normally I aim to get videos
out weekly but right now my baby is keeping me busy so I am aiming for every second week.
Please let me know if you have any questions or if there is anything else you would like

7 thoughts on “Medical vs. Nursing Diagnosis and Collaborative Problems: Know the difference and connection

  1. Do you sell your "videos"? I am a nursing instructor and really appreciate your youtube clips however we do not always have internet access as we are in Rural Ak.

  2. You forgot your Nurse Practitioner, and Midwife colleagues – we also diagnose and treat patients, in point of fact in 21 states, the District of Columbia , and the VA system NP's have full practice authority and are not required to work under the supervision of a physician. In the rest of the US NP's work with a physician collaborator but still diagnose and treat medical problems of their patients independently.

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