ADL care plan

Nascar nurse, ASN, RN · Nov 8, 2009

My goals may state

- will improve ability to transfer AEB requiring only one assist

- Will be able to ambulate "XX" amount of feet with appropriate assistive device (i refer directly to therapy notes and the goal they have made)

- Will be independent with dressing, hygiene and bathing upon completion of OT

edhcinc · Nov 8, 2009

Hi.

Comments--

A "problem" statement describes the the root cause of signs/symptoms/performance that are
problematic

t
o the patient/client/resident
in one or more areas of functioning, thought, mood, health status, living situation, etc. :icon_roll
A "problem" statement
is
not
a sign, symptom, drug, topic, protocol, behavior, category, etc.
that is or could be
- problematic to a payer, facility or staff; or
- "triggered"
  by ordered medical care or assessment instrument; or
- noted in CMS QI/QI:grn:

but

not problematic to patient/cl

ient/

resident.

If patient/client/resident is participating in a rehab therapy program, his/her goal could be -- :idea: reach my prior or optimal level of functional ability as noted, evaluated, and updated in my rehabilitative plans of care.

CapeCodMermaid, RN · Nov 8, 2009

Shouldn't the rehab staff be the ones writing the specific goals for each resident? I usually write "will return to highest level of function. See rehab cp for details.' Never got tagged on this.

nyteshade, BSN · Nov 9, 2009

The rehab department writes their own care plans. I've been trying to convince my boss that we should just use their care plans as the only ADL care plans. But everyone looks at me crazy in the office. So, we have to practically copy the ADL data from sec. G, and put that in the problem section, and form independent goals from therapy. Yet, rehab is doing their own thing. I hate the ADL care plans the most. My boss says we have to care plan everthing that triggers. You see we don't care plan actual problems for the res, rather care plans to "cover". I hate this concept very much. We are very survey oriented. We even had to add silly "problems" to the care plan concerning all the residents that are AAOx3 and choose to eat in their room. I don't think where they choose to eat is a problem...it's a right, but who am I kidding?

CapeCodMermaid, RN · Nov 9, 2009

Well, I know you have to do what your boss tells you, but honestly you only have to care plan things that are a problem. You know you don't have to care plan everything that triggers if you explain in the RAPS why you aren't care planning it. This is pretty basic stuff. If your bosses are making you care plan everything or care plan for survey, you'll always run the risk of missing a real problem and getting tagged on that. Good luck with it all.

edhcinc · Nov 9, 2009

each nurse is responsible for his/own nursing practice. neither my license nor regulations about my scope of practice mention a professional responsibility of or for the "care of surveys", "care of surveyors", or "comprehensive attention to needs of the boss."

if we keep writing care plans to "cover", or for every rap "triggered", or caa "triggered", or new medication, or to acknowledge a preference, or refusing a flu shot, or to wear blue shoelaces on wednesday, we will never have time to think.

for a new patient/client who is staying only a short time, a workable care plan should already be in place by the time the comprehensive mds is done.

this is the time to talk with our peers and with the resident, to figure out there is any underlying problem (or strength) to work on (or with) to assure that the short term approaches work and the goals for discharge are accomplished.
the specific rehab plan with modalities and short-term goals, just like the medical orders, are part of the total plan of care--repeating them makes no sense.
what does make sense is to find out if the patient feels (or the team believes) that this illness or surgery may cause any short or long term problems/concerns, above and beyond his/her normal state of health. the facility staff can help the patient sort out fears from realities or understand that "needing help" is not the same as "helpless".

for the long term resident who now has 54 problems, 100 pages of care plans, and the same approaches on 50 of 54 plans, the comprehensive mds/raps is an opportunity to sort through the "rubble."

are the inability to perform adl's, incontinence, potential for dehydration, skin breakdown, "behavior" issues and lack of participation in activities really only "symptoms" of one underlying problem??
is the "root" problem a progressive decline in cognitive functioning?
a clear definition of the "root" cause makes care planning easier--it can eliminate the need to try approaches that research has shown will never work, and encourage the consistent use of the client's current or present "strengths", likes, or dislikes, in each approach.

this is not to say that we should not add a new problem and associated care plan if the resident experiences an acute medical or surgical problem. during this illness, our approaches to care may change dramatically and should be incorporated into the acute care plan. but once resolved, the basic plan is still intact--to be evaluated and updated when/if there is a change in the "root" cause.

capecodmermaid is 100% right--you and the "team" should focus on what it's really about--the patient/resident and his/her real problems--and planning/providing/evaluating care and outcomes.

do you consider and really evaluate (the) patient's life and needs?

rapkeygurl · Nov 10, 2009

yes this is a problem I have also, as an LVN -- I really do most of the careplanned and raps and then do the careplan to the best of my ability. Seems like everyone keeps wanting me to change the way I do them, each new DON or consultant, or new survey team, I am looking forward to working on careplans in RN school so hopefully I can feel better at this task but you are so right I am trying to use the I care plan stuff a little, I was updating one today and hopefully the nursing staff will look at it because this litle lady has terrible vision and no one helps her cut up her food or help her find her water, because she can not SEE-- I dont think this is rocket science but I always feel like there is something I am missing even after doing raps and stuff. any suggestions would be appreciated. Yes I wish we had a team and not just me --

edhcinc · Nov 10, 2009

How in the world did we get to where ONE NURSE (who is not even responsible for the care of any residents) has been assigned (and accepted) the responsibility for "doing" (and I guess implementing, evaluating, and the outcome from) the care plan?

The nurse practice act in your state may LIMIT who can do this...my state does...

CapeCodMermaid, RN · Nov 10, 2009

yes this is a problem I have also, as an LVN -- I really do most of the careplanned and raps and then do the careplan to the best of my ability. Seems like everyone keeps wanting me to change the way I do them, each new DON or consultant, or new survey team, I am looking forward to working on careplans in RN school so hopefully I can feel better at this task but you are so right I am trying to use the I care plan stuff a little, I was updating one today and hopefully the nursing staff will look at it because this litle lady has terrible vision and no one helps her cut up her food or help her find her water, because she can not SEE-- I dont think this is rocket science but I always feel like there is something I am missing even after doing raps and stuff. any suggestions would be appreciated. Yes I wish we had a team and not just me --

If you have, and you really need to, have CNA care cards or care plans, this sort of stuff should be on them. The CNAs for the most part pass the trays and they are the ones who need to know this information.

rapkeygurl · Nov 11, 2009

well Yes I do update the CNA careplans also, and I just finished looking at the nurse practice act in our state and we had a survey team in and I asked the surverors and of course they told me I could work on them and yes just seems like I do them and hand them over and there is really no discussion but I guess I at least talk to the family and residents and try not to put unreasonal approaches but I have been a nurse 20 years and worked the floor many days so I do know what the nurse aides and nurses will and will not do. and I talk to the nurse aides a lot because you are right they are the ones taking them to the toilet, feeding them, etc... and I cant seem to get thru to them to please chart to get credit for what you do. They had been putting totally independent on someone that can not see--- Hello!!! Then I asked 3 people today nurses and aides do you have to cut up her food?, do you have to help her get dressed, (the response was, she sleeps in her clothes) dang -- She did not a little over a year ago when I was working the floor, because we helped her get in her pj's? I do teach the majority of our nurse aides but it is just a little 54 hour course and I try to give information etc.. , If I dont at least initiate those careplans we will get a defiency but I never ever sign that I am doing that because I expect them to review the mds and the careplans I am only human I do make mistakes and have had DON's tell me you need to do a correction on such and such in the past and I gladly do because I go to work wanting to do the best I can even if it is paper work, but I do get my hands dirty, today I toileted a couple, obtained weights for my mds people that were do. Made rounds with one of the docs - so the nurse could listen to the staff meeting. In a small facility we do it all sometimes we take residents on transports, god forbid take laundry to get washed when equipment breaks down. I do venipuncture when someone has a difficult stick. Believe me I am not afraid to say that is above my scope of practice, because I have several times when we had no DON for almost 6 months and I was ADON, and I called my state board and went on maturnity leave early due to the situation and Had a new baby at home and was called all the time just to ask how to transmit and mds. I am far from perfect and that is why I am back in school. I want to be a better nurse and for 2 days have been avoided regarding training for the restorative program.

susanthomas1954 · Nov 14, 2009

This whole thread is the Stephen King novel of MDS world, imho. Every new admin and DON has their own idea of how I should write THE care plan, and the floor nurses who see the patient most frequently can't even grab a pre-printed UTI care plan and personalize it. Most of the time, they can't even tell me if the patient is even continent! Thank the good lord that no one relies on the care plan for the actual care the patient receives! (Seriously, I have written Nobel Prize eligible care plans that DON's feel comfortable criticizing because of what the surveyor won't like!)

ST