Nursing Care Plans - page 2

Hello everyone! I am currently enrolled in a CNA course and will be applying to the RN program very soon. In my CNA class, patient care plans are pushed big time. Everything we go over (ROM, BRP ect) is said to be somewhere... Read More

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    Part of the point of care plans in nursing school (and I don't know a soul who liked them!) is to get you thinking about what the patient needs, based on his medical diagnoses, your physical assessment, and whatever treatments have been ordered. You list these needs, you list interventions you can perform to meet those needs, and you evaluate whether they worked or not.

    For nursing school, the care plan is usually a one-time thing, set to help you think about your patient(s) for clinical and how you will best take care of them for those several hours. In nursing-world, you do the same thing...only most of it takes place in your head, and it takes place many many times over in the course of a shift, and most of it never gets written down.

    On my floor, there is a preprinted plan of care. Nursing diagnoses, interventions, and desired outcomes are preprinted, and we check them off as applicable. It has to be opened on admit and the problems closed as appropriate. Once the problem no longer applies, there is a space for us to sign and date indicating we've 'closed' that problem. There are also blank spaces for us to use in case none of the preprinted stuff applies to a particular problem. I work nights and when I do chart audits, I take a look at the careplan to see if anything needs to be closed or opened. Other than that...I will be honest, I don't think anyone actually looks at them. But they are a requirement.

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    The hospice I work for requires that we create a nursing plan of care, using NANDA type language, and document patient progress toward goals regularly. Our POCs are electronic and we can customize the problems, interventions, and goals as needed...or we can simply choose from a comprehensive listing.

    All professional health care disciplines document a plan for their care of the patient. In many instances it is a requirement for reimbursement...and in instances where it currently is not, it may be required soon enough.
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    I'll never get away from them.
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    Thanks so much for all your input!! It's definitely greatly appreciated!

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    Thinking through what goes on a care plan is not at all difficult. Documenting, through report writing, is not difficult. Regurgitating all of that in nurse speak is, however, overly time consuming. The difficulty comes only from trying to keep the verbiage and format like that of an instructor sample.

    Just out of curiosity, have any studies been completed and published stating whether NANDA language care plans actually improve patient outcomes?

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