Nurse Practitioner Angela Golden explains why ordering diagnostic testing should not be an NP’s first response.
Angela Golden, DNP, FNP-C, FAANP, provides clinical services as a family nurse practitioner in her own practice, NP from Home, LLC, in Munds Park, Ariz., and in urgent care settings. She has authored and co-authored numerous peer-reviewed articles and chapters, and has presented locally, nationally and internationally on varied topics related to nursing and advanced practice with a special emphasis on health policy issues. Golden presented “Improving Your Diagnostic Skills and Clinical Intuition” at the American Association of Nurse Practitioners 2015 Specialty and Leadership Conference. We asked her to tell us more about that presentation.
A: Taking a good history and doing a good physical examination help to narrow down the differential diagnosis. And it can assist in learning what is going on with the patient as opposed to relying on diagnostic testing. There’s good evidence all of us in healthcare have started to rely on such testing instead of our diagnostic skills, which is about listening to the patient’s history and trusting ourselves. Intuition is being open to more information and a way of processing the skill with your five senses. It’s not a mystical power. It’s part of an analysis and response process.
A: It’s important to being a quality, cost-effective clinician. Every time we order tests, we increase the cost of healthcare. Ordering tests are important in many situations, but we need to choose wisely and make sure those tests are adding value to our diagnostic reasoning. The Choosing Wisely campaign and the Ottawa rules for X-ray ordering are examples that can help nurse practitioners decide when to order a diagnostic. Everybody should be concerned about the costs of the healthcare system. It will bankrupt the country if we don’t get it under control.
A: The only reason to order a diagnostic test is if it will change the patient’s treatment. There are some legal liability concerns, and at times, tests are ordered to confirm what we know. We spend a lot of money in our healthcare system ordering tests that may not be necessary if we did a better job of using a good physical exam with excellent history taking.
A: No. It’s part of the nursing process. It’s the ability to process the information from your five senses and from your past experiences. Intuition is a natural process and it occurs if you pay attention to it. You learn to trust it by keeping a record of the times your diagnosis was correct, without ordering the tests or later having it confirmed by tests. Clinical intuition can help us make complex clinical decisions to benefit patients. It is important that nurse practitioners learn to recognize all of the information at their disposal and to learn to trust themselves.
A: If a patient comes in with a cough, an elevated temperature, no travel, no vomiting, no symptoms of an upper respiratory viral infection, I proceed with a good physical exam with that patient. A good HEENT exam reveals all normal findings. I then auscultate the chest and hear increased bronchial sounds in the right middle lobe. Then I perform percussion, egophohy and fremitus. Those are skills all nurse practitioners learn in their assessment course, but don’t use very often. By doing those four things, I can make a diagnosis and do not need a chest X-ray. The patient has consolidation in the right middle lobe. With a temperature and sudden onset, I diagnose the patient with community-acquired pneumonia.
A: Practice all of the skills learned in your physical exam class. Start making a diagnosis before ordering a test and start learning to trust your diagnostic skills and intuition.