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Diagnosis

6

(1)

A registrant in the course of practising nursing may…

 

 

(a)

make a nursing diagnosis identifying a condition as the cause of the signs or symptoms of an individual

The Regulation sets out the type of diagnosis registered nurses can make. Specifically, registered nurses can make a nursing diagnosis that identifies a condition—not a disease or disorder—as the cause of a client’s signs or symptoms.

This diagnosis is a clinical judgment about the cause of a client’s mental or physical condition. It is made to determine whether the condition can be improved or resolved by the registered nurse intervening appropriately to achieve a result for which the registered nurse is accountable.

Registered nurses diagnose and treat a variety of conditions. Some conditions can be resolved with nursing treatment. Others can be stabilized or improved by registered nurses but require the involvement of another health professional to diagnose and treat the underlying disease.

Some conditions result from a known disease or treatment of that disease (e.g., hypoglycemia, urinary retention, constipation related to medication). Others require stabilization until the underlying disease or disorder can be diagnosed and treated (e.g. severe bleeding, hypoxia) by a physician. ). Examples of other conditions registered nurses diagnose and treat include anaphylaxis, constipation related to diet, some wounds, minor second degree burns and foreign object in the eye without corneal abrasion.

Before treating a condition, registered nurses must first collect information using their assessment skills and then draw a conclusion (i.e., they must diagnose the condition).

In some practice settings and roles, organizations may establish policies and processes that support RNs to conduct a nursing assessment to make a clinical judgment of a client’s mental or physical condition to arrive at a ‘provisional diagnosis’ or ‘diagnostic impression’ for initiating triage or other nursing activities in a timely manner, as permitted by their scope of practice. The purpose of the ‘provisional diagnosis’ or ‘diagnostic impression’ is to initiate nursing care; it is not, and must not be treated as, a formal diagnosis of any disease or disorder. Such a formal diagnosis can only be provided by an authorized health professional after they have personally assessed the client.

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