Care plan help

Sep 16, 2009 09:56 AM

by Schmoo1022

Hi,
I think I have mentioned a few times that I come from a very small facility. We were not responsible for updating the care plans. I know this may sound crazy to many of you, but that's how it was. We wrote any changes in a MDS book and either the MDS nurse or the Director updated the care plans. So, now I am going to a huge facility and of course I am going to update the care plans....how the heck do I do this?? Say if someone is no longer able to stand and pivot for transfers and I got an order for a sit and stand. Do I just write , "9/17/2009 Patient to use sit and stand for all transfers" ? Is there any website or books that could help me with careplans?

mwilliams86 · Sep 16, 2009, 10:39 AM

Re: Care plan help

Nursing Diagnosis Handbook by Betty Ackley and Gail Ladwig

jmtndl · Sep 16, 2009, 11:04 AM

Re: Care plan help

Don't sweat it...nursing care plans are and have always been meaningless paperwork compliance.Figure out the easiest and quickedst way to do what ever they want you to do to "update the careplan" and do it, then forget about it. Nursing care plans are the most useless thing ever invented. Don't waste your brain cells on the...just worry about the patient and what you do for them, not JACHO.

Schmoo1022 · Sep 16, 2009, 11:49 AM

Re: Care plan help

LOL, they may be "useless", but you can get into mucho trouble from the state if they are not updated. I am not going to worry about it too much. I will just start checking out the care plans in the chart and go from there

misslo · Sep 16, 2009, 02:41 PM

Re: Care plan help

http://www.careplans.com/default.asp

nyteshade · Sep 16, 2009, 04:05 PM

Re: Care plan help

I am a MDS nurse. First, I would advise you to check with your MDS nurse about to what extent you are updating. In my facility, I do all my own updates. Anyways, the basics would be updating things like medication changes. For example, if there is a HTN careplan, if they had "Coreg as Rx" and the order changes to Diovan, then you would D/C the Coreg in the careplan. I never put doses because they can change too much, ie; Coumadin. FYI: if you note declines/improvements in cognition/pressure sores/ADLs/B&B, etc notify your MDS nurse, because this is more than just updating a careplan at that point.

CapeCodMermaid · Sep 16, 2009, 05:31 PM

Re: Care plan help

Each facility has a different idea about care plans. Some want every little detail care planned such as the names and doses of the medications, and some want things more vague. Find out what your facility wants. You don't need to care plan things that aren't a problem. You should, however, set realistic goals and interventions. I am a firm believer that ALL nurses need to update care plans. Why should the MDS nurse be the only one?

nyteshade · Sep 16, 2009, 06:26 PM

Re: Care plan help

Originally Posted by CapeCodMermaid

Each facility has a different idea about care plans. Some want every little detail care planned such as the names and doses of the medications, and some want things more vague. Find out what your facility wants. You don't need to care plan things that aren't a problem. You should, however, set realistic goals and interventions. I am a firm believer that ALL nurses need to update care plans. Why should the MDS nurse be the only one?

Why should the MDS nurse do all the updates?! I wish my facility did that. I got 40 long terms (always sick and changing status) and 20 Medicares (rehab) of course the residents are like revolving doors on rehab. I alone do weekly updates

*Daytonite* · Sep 17, 2009, 07:22 AM

Yes, to keep in compliance, make an entry like you did that is dated with your nursing order under the proper nursing problem (nursing diagnosis). I used a care plan book by Carpenito for years when I did care plans in LTC because she had some nice nursing interventions in them by medical conditions. If you go on a website like Barnes & Nobel and pull up care plan books look through them and see what they've got. In particular, look at the table of contents pages of each. I haven't checked lately because I haven't been working, but there may be care plan books out there specifically for LTC that address the problems in LTC that would be more appropriate. It's always easier to look up an intervention rather than sitting there racking your brain trying to figure out what to write down. The same handful of nursing diagnoses tend to get used in LTC so I don't know that it's necessary to get a nursing diagnosis reference.

I also had pre-printed care plans for things like skin tears, falls, a fever, and little stuff like that that came up and would tie me up for a hour in paperwork. I would whip one out and fill in blanks on it and was good to go. These got stuck in patient charts as needed.

makes needs known · Sep 21, 2009, 11:32 AM

Re: Care plan help

Head nurses at our facility have been asking the LPN to start care plans on new admission patients . We just had a survey conducted and when it was discovered that care plans had been initiated by LPN, they informed us that according to NYS regulations, care plans have to be started by the RN.

New To Site	Need Help	Quick Links
Create An Account General Site Map allnurses.com Journals Terms Of Service Privacy Policy Testimonials Meet Our Staff Advertising Information	Information Center & FAQ Boards of Nursing How-To Video Tutorials Did you forget your password? Compare Membership Contact allnurses.com Text Version Mark All Sections As Read	United States Nursing International Nursing Nursing Specialty Advanced Practice Nursing Critical Care Nursing Nursing Specialties Get In Touch... Find Us On Facebook Follow Us On Twitter

Care plan help

Care plan help

Nursing News

Interesting article on ThedaCare's Collaborative Care Model

Possible breakthrough regarding MS

16th Philly area hospital to stop delivering babies: Mercy...

Really interesting article on Indian open hearts

High-Tech Pump Does What Her Heart Can't

Air Force RN Found Not Guilty

California Imposes Stricter Rules Regarding Drug Abuse In...

Are older nurses being forced out of the profession?

An outlook in California?

Australian surgeons successfully separate conjoined twins

Nursing Articles

Society Needs Care Too

Why am I doing this, anyway?

Nurse Heal Thyself

My Papa, why I am the nurse I am today.

I made it through

An angel's gaze

A Sister Never Forgets

Ruby's Marbles

What Do Operating Room Nurses Do?

My Little Old Jedi

I love this job......

"I hear voices"

Preventing FRUTI (Foley Related Urinary Tract Infection) in...

Error and Attitude

It's Just a Shower

Available Topics (tags)