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Diagnosing and treating conditions


​​Although the terms may not be familiar to you, it’s likely that you’re already diagnosing and treating conditions in your practice.When you plan for and provide psychiatric nursing care, you’re making clinical judgments about your client’s status and carrying out appropriate psychiatric nursing treat​​​ment.​​​

For example, based on your assessment:

  • You diagnose acute confusion in your client, and decide to withhold antipsychotic medication, check vital signs, perform a glucometer to assess blood sugar level, and perform a mini-mental status examination.
  • You diagnose hypoglycemia in your client with diabetes, and treat it, following your organization’s hypoglycemic decision support tool (DST).
  • You assess abdominal pain and distention in your elderly client with a known urinary tract infection, and apply ultrasound using a bladder scanner to diagnose urinary retention
  • You diagnose an immediate risk for physical violence from a client who is no longer responding to other de-escalation interventions and determine a reduced stimulation secure room is required following your organization`s policy/protocol

Diagnosing

In B.C., diagnosing (a disease, disorder or condition) is a restricted activity granted to some regulated health professionals. For instance, physicians and nurse practitioners are authorized to diagnose diseases, disorders and conditions. Registered Psychiatric Nurs​es (RPNs) have the authority to diagnose conditions only.

Conditions

Conditions usually have associated signs and symptoms such as abnormal temperature, pulse or pain. However, in mental health there may be exceptions when the signs and symptoms may not be as readily observable, for example, internal suicidal ideation, thoughts of paranoia, or anxiety. A condition may also be the result or be related to a known disease, disorder or its treatment. 

For example, an RPN may diagnose a disturbed thought process in a person who has schizophrenia, chronic confusion in a person who has been diagnosed with Parkinson​​​'s disease, hypoglycemia in a client with diabetes, or angina in a client with a history of coronary artery disease. Other conditions, such as hypoxia, or pain may result from a medical problem such as an undiagnosed disease or disorder. In these situations, an RPN may diagnose and stabilize the condition until another authorized health practitioner diagnoses the underlying disease or disorder.​​​​​

Examples of conditions that may be related to a disease or disorder

In addition, there are some conditions that psychiatric nurses are able to treat to resolve, and others they are able to treat to stabilize until seen by another health professional. These 2 tables provide some examples of both.

Conditions that RPNs may diagnose and treat to resolve Conditions that RPNs may diagnose and treat to stabilize
Possible Condition Disease or disorder Possible Condition Disease or disorder
Constipation related to medication​Iron Deficiency/AnemiaRespiratory distressAsthma
Urinary retentionUrinary Tract Infection/ Post-operativeHypoxiaAsthma, Chronic Obstructive Pulmonary disease
PainLung Cancer/ ArthritisAnaphylaxisAllergies
Paranoid Ideation/Disturbed Thought ProcessMental health disorder – SchizophreniaAnginaCoronary Artery Disease
HypoglycemiaDiabetesAnxiety/IrritabilityMental health disorder/Nicotine Withdrawal
Disturbed Sensory/Thought PerceptionDeliriumRespiratory depressionOpiate overdose
FearPhobiaSuicidal ideationMental health Disorder-Depression
Self-mutilationBorderline Personality DisorderHypovolemiaSepsis, trauma
ConfusionDementia
Imbalanced Nutrition: Less than Body RequirementsSubstance Use Disorder/Eating Disorder​

Controls on RPN practice – what should I consider?​​

There are four levels of control on RPN’s practice:

  1. The Health Professions Act and the Nurses (Registered Psychiatric) Regulation which sets out the broad scope of practice (this applies to all RPNs)
  2. CRPNBC standards, limits and conditions, which complement and further define and limit the scope of practice set out in the Regulation (this applies to all RPNs)
  3. Employer/Organization policies¹, which may further restrict what activities an RPN may do in the workplace (this applies only to RPNs at that workplace)
  4. Individual RPN competence to carry out a particular activity, which reflects an RPN’s level of education, knowledge, skills, experience and currency (this applies to an individual RPN)

¹ RPNs in independent practice assume the responsibilities of employers.​


The legislative authority

The Nurses (Registered Psychiatric) Regulation provides the authority for RPNs to make a nursing diagnosis identifying a condition as the cause of a client’s signs or symptoms. In the Regulation “nursing diagnosis” means:

“a clinical judgement made by a registrant of an individual’s mental or physical condition to determine whether the condition can be ameliorated, or resolved by appropriate interventions of the registrant to achieve outcomes for which the registrant is accountable”.

It involves drawing a conclusion about what is causing the signs or symptoms you have recognized.

BCCNP RPN Standards, Limits and Conditions

BCCNP RPN scope of practice standard Autonomous Scope of Practice and Client-specific Orders consist of the following standards:

  • Acting within Autonomous Scope of Practice 
  • Acting with Client-specific Orders 
  • Giving Client-specific Orders ​

The standard Acting within Autonomous Scope of Practice outlines the requirements necessary for RPNs when acting within autonomous scope of practice.

What is Autonomous Scope of Practice?

‘Autonomous Scope of Practice’ includes the restricted activities listed in Section 6 of the Regulation and the provision of other care or services that do not involved restricted activities, except for any activities, care or services that are excluded from autonomous scope of practice.

What is excluded from Autonomous Scope of Practice?

‘Autonomous scope of practice’ excludes any activity, care or services:

  • Listed under section 7 in the RPN Regulation (to the extent the care provided is not within the activities listed in section 6.)

Prohibited by:

  • Any standards, limits or conditions established by BCCNP, including the BCCNP Scope of Practice for Registered Psychiatric Nurses: Standards, Limits and Conditions; or
  • Any applicable organizational policy, procedures or restrictions.

What’s my accountability?

When you diagnose, and decide to treat a condition, you assume sole accountability and responsibility for the diagnosis, appropriate treatment, and your client’s outcomes. When doing so you follow a clinical decision-making process by:

  • Assessing the client’s status
  • Making a nursing diagnosis of a client’s condition that can be improved or resolved through nursing activities
  • Determining the activity to be carried out
  • Carrying out an activity to treat, prevent, palliate, an injury or illness and/or improve or resolve a condition
  • Managing the intended and unintended consequences of carrying out the activity
  • Managing and evaluating the outcomes of the activity

Depending on the activities you are carrying out, there may also be BCCNP limits and conditions in place. For example, you may determine a client requires an intravenous infusion to manage hypovolemia. However, BCCNP has both a condition (an RPN must have additional education) and a limit (only short peripheral devices can be used) in order to perform venipuncture with or without an order.

The following documents contain additional information to support you when diagnosing and treating conditions:

  • Medication Administration​ practice standard
  • Consent practice standard
  • Dispensing Medications practice standard
  • Documentation practice standard
  • Professional Standards​
  • Scope of Practice for Registered Psychiatric Nurses: Standards, Limits, Conditions

Ask yourself:

How do I apply the standards for Acting within Autonomous Scope of Practice?

Are there any limits and conditions on the activities I plan to carry out?

  • What needs to be included in a client-specific order?
Employer policies and resources

Organizations establish processes, supports and resources such as policies, procedures, and Decision Support Tools (DSTs) to outline expectations and support evidence informed psychiatric nursing practice when diagnosing and treating conditions and ensure that RPNs meet the standards set out by BCCNP.

These DSTs may be called:

  • Clinical practice standards and procedures
  • Protocols
  • Algorithms
  • Clinical Decision Support Tools (CDSTs)

Be aware that when you carry out any activity within autonomous scope of practice, even when following a DST, you are solely accountable.

Organization policies may also limit the practice of an RPN in a workplace setting. Before carrying out an activity within autonomous scope of practice, you’ll need to make sure it is within any restrictions set by your organization.

If there are no existing organizational policies or procedures, RPNs follow up and seek direction from the employer, clinical resource or practice leader.

Ask yourself:

  • What employer resources can support me to diagnose and treat conditions?
RPNs' individual competence

RPNs only perform activities and provide care or services that the RPN has the individual competence to carry out.

​​

Communication, documentation and collaboration

RPNs clarify their roles and responsibilities in their organization when acting within autonomous scope of practice. See RPN scope of practice standard Acting within Autonomous Scope of Practice for more​​ details.

RPNs work with other members of the health care team to provide clients with safe and effective care. Consider how you communicate and consult with others on the team. You may seek advice from colleagues or consult with listed or non-listed healthcare professionals before arriving at a nursing diagnosis, finalizing a plan of care, or determining the most appropriate treatment for a client.

Ask yourself:

  • How do I communicate my diagnosis, plan, treatment and client outcomes to other team members?
  • How does my documentation reflect this process?

Things to remember when diagnosing and treating

  • Diagnosing involves critical thinking and judgment.
  • Conditions have associated signs and symptoms.
  • Diagnosing a condition involves determining the cause of your client’s signs and symptoms.
  • You diagnose the condition to determine whether you can improve or resolve it with psychiatric nursing treatment.
  • Diagnosing a condition is linked to the standard Acting within Autonomous Scope of Practice. You determine the plan for treating a condition; your plan is based on what you’ve decided the likely cause is.
  • Your assessment might identify a medical problem and lead to a request for assistance/client-specific orders.
  • You do not treat if you cannot manage the intended and unintended outcomes.
  • Evaluating treatment can help rule out, refine or validate your diagnosis.

Think about the clients in your clinical practice, and consider the conditions you may diagnose and treat.

Ask yourself:

  • What is the clinical decision-making process I use when I plan for and provide care?
  • How does diagnosing conditions fit into my practice?
  • What knowledge, skill and judgment may be required?​
Putting it all together: case scenario

Can an RPN diagnose and treat Anaphylaxis?

Mike, an RPN, can hear the two approaching even before his client, 28-year old Simon and his co-worker arrive at the nurse’s station at the mental health group home. Simon is experiencing some nasal congestion and describes how he has just been stung by a wasp while showing Mike his red, swollen shoulder.

As he sits Simon down to examine him more closely, he listens to a recounting of the event. Simon is visibly anxious, his skin flushed and blotchy and his breathing has become a little wheezy. His concern increased, he asks Simon if he is allergic to bees or wasps. Simon states he doesn't know as he has never been stung before. 

Mike can see swelling beginning around Simon's mouth and his breathing becoming more labored. Checking Simon’s pulse, he finds it rapid. He’s certain Simon doesn’t have any allergies to medications – he’s reviewed his chart including his medical history and medication records and there are no known allergies listed. Mike runs systematically through his assessment – a rapid pulse, anxiety, red blotchy rash, facial angioedema and wheezy, labored breathing.

In his clinical judgment, these are signs of anaphylaxis. He knows the treatment is prompt administration of epinephrine. Deciding on his next steps, Mike calmly explains to Simon that he’s likely reacting to the wasp sting and asks his co-worker to call 9-1-1.

Can Mike treat Simon without an order?

Yes, under the Nurses (Registered Psychiatric) Regulation, Mike is authorized to diagnose and treat conditions. This includes administering Schedule I medications without an order to treat certain conditions. The scope of practice for RPNs sets standards, limits and conditions under which Mike can give epinephrine to treat anaphylaxis. The standard, Acting within​ Autonomous Scope of Practice, outlines the requirements for Mike when he carries out an activity within autonomous scope of practice. BCCNP further sets conditions that require Mike to have additional education and follow an employer approved decision support tool (DST).

What does Mike do?

Following the employer's anaphylaxis protocol, Mike carefully draws up the correct dose of epinephrine. He explains to Simon that he needs to give him an injection of medicine to make his breathing easier. Reassuring him that it will be quick, he talks him through the procedure.

Within minutes, Simon’s breathing becomes less labored and his facial swelling decreases. When Mike checks his pulse, he’s relieved to find that its quality has improved. Shortly after this, the ambulance arrives and Mike provides a quick report to the paramedics. While the paramedics perform their own assessment, Mike documents the incident and his actions. As Simon is loaded into the ambulance, he assures him that he will notify his next-of-kin. When the ambulance carries Simon away, Mike breathes a sigh of relief.

How is Mike meeting the standards for acting within autonomous scope of practice?

Before treating Simon, Mike assessed him, diagnosing anaphylaxis as the condition associated with a wasp sting as the likely cause of his signs and symptoms. Having previously obtained the required additional education, as set out in the BCCNP Scope of Practice for Registered Psychiatric Nurses: Standards, Limits and Conditions, he knew he could improve or resolve Simon’s condition with nursing activities – including administering epinephrine. 

In deciding to treat Simon, Mike considered the risks, benefits and possible outcomes. In his judgment, the outcome was reasonably predictable and the benefits outweighed risks. He knew he had the competence to administer the epinephrine safely and manage any outcomes. He followed an evidence-based protocol/DST and knew his actions were within agency policy. Mike understood he was solely accountable for his decision to treat Simon and confident it was the right one.