Care plans in the LTC setting

[sheebs_]

I'm new to the LTC setting and was just recently promoted to director of nursing. I'm in charge of initiating care plans for all the residents in my facility. I've been told that if a resident is admitted to us with a medical diagnosis of "hypertension", then we can write our problem in the care plan as "the resident has hypertension". To me that doesn't seem right. I was just wondering if anyone could help me transition into this new position more easily. I feel like I'm not getting very direct answers and being that I'm kind of a perfectionist, I want these care plans to be done completely right. I always thought we could only write a nursing diagnosis in a care plan problem so any help or direction would be greatly appreciated! Thanks!

[classicdame, MSN, EdD]

I would first go to your Nursing Practice Act to determine what is required of nurses in long term care. Then I would get membership on the Joint Commission website, and Health Department and anyone else who surveys your facility. I imagine the facility might require the medical diagnosis to be on the care plan, but it could also be that whoever made that policy was not aware that nursing diagnoses are not the same as medicals. So you have to get your evidence to show the correct way of doing it. I have not worked in LTC, but I imagine there is a professional agency for LTC nurses and I hope you are a member. Glad you are striving for the best!

[firstinfamily, RN]

Are you computerized system or doing care plans the old fashion way of hand writing them? When we were computerized in LTC the program that was used was Point Click Care (PCC) and the care plans were pretty much programmed, you just had to pick from their selection the ones that pertained to your patient. When we were paper we would have pre-typed care plans and specialize them for the patient. For example: The patient with HTN I would start with: Potential for inadequate Cardiac Output related to HTN, and put in a measureable goal for B/P range will fall within . . . . . We were also required to list the medications the pt was on that would be treating the nursing diagnosis, so I would list all the cardiac/b/p meds that pertained to HTN. Hope this helps a little!!!

[sheebs_]

We actually use PCC and I find the templates are very basic. In fact, in our other facility (under the same corporation) said their state surveyor mentioned PCC's care plans not being adequate enough. I prefer to use the "potential for inadequate cardiac output r/t HTN" as well but the PCC template just states "the resident has HTN" and then some wonky goals. The interventions aren't bad...I'm just having issues with their problem templates.

[NurseMellie]

I also use PCC and use the basic template as a guide not necessarily as how it will be written or turned out... You can pull items straight from the MDS after CAAs are written.... now if you import all of those your care plan will be needlessly long... So when I have that template open, I copy and paste to a word document the problem, my goal and my intervention that I want to use. A lot of those need to be tweaked and that's ok. For the problem list; you can use medical and nursing dx, alteration in health maintenance is usually my biggest one. Then I move over to my goals ..... For example for HTN: John will not have complications related to hypertension through review date. (yes this works for our surveyors), then in my interventions I copy over the items to look for related to malignant hypertension. Some of these need to be tweaked to state to report to LN or MD you can have both just make sure its showing in the proper areas; NACs, LN, SS etc.. We also add in the interventions: Med/TX and Labs as ordered. We don't have to spell them out necessarily. You can also created a data base just for your facilities if your corp office agrees of course..

In our data base we have things like: (resident) requires 1 set up assist for dressing... So where it says resident, the resident's name goes there, even those can be tweaked. But becareful on how much you have on there,,, we try to limit our kardex to one page for the NACs so anyone can go into that room and take care of the resident.

Im most places the MDS/RCM is responsible for doing the careplans so I find it odd that a DON is doing those.. how big of a facility?

[amoLucia]

In many places, all licensed nsg staff are expected to contribute to the care plans and they were TO BE STARTED on admission with SOMETHING.

As staff RN/supervisor, I liked to do care plans. But mine never seemed to be fancy like yours are all made out to be. Hypertension to me is a medical dx. Now if the pt's BP were uncontrolled and was experiencing TIAs or other S&S, that's the problem. 'a risk for ... r/t diagnosis. I'd have the goal 'BP will be within range ...', interventions, and a 'by date'.

I found that many staff are intimidated by nsg care plans. Oldsters prob didn't have much experience with the formal care planning format, but they know the problems. Newbies are struggling along but they're still thinking 'schoolish'. Our care plans WERE NOT fancy, and we had no problems with survey. Staff really did try to add to them, esp interventions when they were started. And we covered a lot of issues. I did care plans by hand, bu tsomeone else's care plan would serve as a sample. And we did have some preprinted ones

So my advice to OP would be to think simple and not be too critical. Or else nobody will be doing them. And staff should be working on them. They may need inservice workshops with samples. Get your supervisors to involved.

I always seemed to have problems with the ADLs. On 11-7, not too many ADLs are presented. So the UM did them and I could do other problems (safety, psychoactive meds, IVs, wounds, diabetic (my fav), etc). It seemed to work out very well for us.

[CapeCodMermaid, RN]

You're the DON and you're expected to do care plans? How big is your facility? Is the hypertension a problem or merely a diagnosis? I carry the diagnosis but it is NOT a problem for me so I wouldn't expect it to be in a care plan.

[sallyrnrrt, ADN, RN]

my sentiments exactly capecod :)

[NurseMellie]

All licensed staff in my building are responsible for careplans. On admit, the admission nurse starts one and puts basic items in, transfers if known, glasses, dentures, hoh etc. More of that is filled in as we get to know the resident.

If someone has a dx in their history, it doesn't always mean it makes it into the problem area of the care plan. Is in one they've had in the past? History of.... This won't always be on my careplans. If it is something actively being treated, it will be on my care plans. Another rule of thumb, if it requires monitoring in anyway, it should be listed.