Truth about Nursing diagnosis

[UTRN2005]

I'm a student and I was just wondering how much you actually use written 3-part nursing diagnoses and pt goals and nursing interventions and evaluations in the real world. Our program seems to stress them a lot more than what I've actually seen them used in clinicals. Thanks.

[bunsterj]

I used to write tons of care plans, and I honestly think they were rarely read by anyone other than supervisors to see if they were done, and the JACHO folks.

The problem I have with them, is that the interventions tend to be so generic. If they was at least some that were unique to that patient, I and perhaps others would be more interested in reading them. For example a few posts back someone had mentioned a ND of "diversion activity deficit" or the like, I would like to see interventions that work for a particular patient. Many years ago, we had a pt. on our floor that was pretty much restricted to a Clinitron bed, she had some neuromuscular problems and had been on our unit for a long time. She was very alert and bored silly. What the regular nursing staff knew was that on each Thursday PM, two LDS Missionaries came by to play Scrabble with her (as they did when she was at home). This was very important to her. If you floated to our floor, you wouldn't know this. Had it at least been mentioned on her care plan, you would know to not attempt to do her lengthy dressing change during that time and to hopefully get her assessment done very early or much later in the shift as this was the highlight of this woman's week.