Nursing Care Plans

  1. 0
    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 in the patien's care plan. In quite a few threads I've read on here, I've noticed that it's been said that most of the time nurses dont even have time to even look at the care plans let alone follow them. Is this true? How does one go about assessing the patient's needs if the care plan isnt utilized?

    Thanks again!

    Ashleigh

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  2. 14 Comments...

  3. 1
    Quote from SkinnyLatte
    Hello everyone!

    How does one go about assessing the patient's needs if the care plan isnt utilized?

    Thanks again!

    Ashleigh
    By using your critical thinking skills. You know why the patient is there, you know his/her diagnosis, and you know what typical needs a patient would have with that diagnosis. The rest, you're generally able to figure out by observing the patient, assessing the pt, talking to the pt, etc.
    sunnycalifRN likes this.
  4. 2
    Use the Kardex, the chart, the patient's expectations and your own assessment skills to determine the plan of care.

    The traditional care plans have gone the way of the dinosaurs... extinct.
  5. 0
    Thanks so much for your input. I was just wondering how much emphasis is put on the care plan b/c it's definitely pounded into our head in class. Care plan. care plan. care plan. And my teacher is an RN but it just kind of makes me wonder how much she's actually used one in her career or if she's pushing it b/c the curriculum requires it.
  6. 0
    Quote from OttawaRPN
    The traditional care plans have gone the way of the dinosaurs... extinct.
    I wish. I think JCAHO still has an expectation of them.
  7. 1
    Why do you need a care plan at all to make an assessment, diagnose, and intervene? You don't.
    roser13 likes this.
  8. 1
    It depends on the facility where you work. At my hospital we use computerized charting and the expectation is that each shift will complete care plans. This includes a problem list and whether the pt has met this goal and it is no longer applicable, whether it was met this shift, whther they are progressing, or whether the pt has not met this goal. If they have not met the goal we fill out a variance for that problem and state the problem, interventions, pt's response, and follow-up actions. It sounds tedious, but really it only takes a few minutes and I like them because they really makes you think about some things that you otherwise might not have time to stop and thing about, i.e. what ARE we doing about the patient's elevated BUN and creatinine?
    flyingchange likes this.
  9. 1
    Quote from SkinnyLatte
    Thanks so much for your input. I was just wondering how much emphasis is put on the care plan b/c it's definitely pounded into our head in class. Care plan. care plan. care plan. And my teacher is an RN but it just kind of makes me wonder how much she's actually used one in her career or if she's pushing it b/c the curriculum requires it.
    You got it! The care plans that we're all taught in nursing school are definitely not used. I'm sure that all nurses have a general plan of care for each patient, in their head, but you don't have time to write one out, with multiple nursing diagnoses (puke!!). Maybe there's a nursing instructor on Allnurses who uses a written care plan . . . but most bedside nurses don't have time.
    Bella'sMyBaby likes this.
  10. 0
    Just like other disciplines must document their professional assessments and plans to correct or improve any issues, so also must nursing.

    Many acute care nurses work from a medical rather than nursing POC, but there is a nursing POC in the chart...or at least should be.
  11. 0
    Our plans of care are a check off. It's updated with each recertification period and PRN.


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