Care plan & clincal question

[Zelda21]

I'm just curious to know how other schools do their care plans. First off- I have no problem writing my care plans - but my school requires we go in the day before clinical and write down information on a pt (dx, hx, meds etc.), but we are not to meet with the patient. We then come to clinical the next morning with completed drug cards, a care plan (to be revised and followed) and a patho paper started.

What baffles me is that I am to write my care plan without my initial assessment. During clinical last semester we had time to revise our care plans if they did not make sense, but I kind of feel like I was just making things up until I did my head-to-toe. After a few rotations I caught on to read the prior nurse's assessment and that certainly helped, but we really just guessed and hoped the plan fit our patient.

Do other schools do care plans this way?

[nurseprnRN, BSN, RN]

You are exactly correct. You are making it up until you do your own assessment. Good for you in at least getting the RN assessment as a hint as to what you might be encountering, and extra good on you for knowing you will need to revise by at last citing your own current assessment data.

From what I read here, a lot of students pull their nursing plans of care out of, umm, the air because they sounded good. Or they think that there is some one from column A, two from column B list where you can choose nursing diagnoses based on medical diagnoses. It so totally does not work that way, and we spend a great deal of time here trying to explain that. Sounds like you already understand, and bless you for it! We appreciate it.

[november17, ASN, RN]

It probably doesn't make much sense now but in practice it will help you think on your feet. sounds like youre doing the right thing. In practice the care plan continually evolves.

[akulahawkRN, ADN, RN, EMT-P]

Where I'm at, we do something similar. We go to the hospital a day early to do prep on our patients. We get the meds, medical history, and so on. I usually also look at the nursing, physician's, and specialty (PT/OT/SLP/etc) notes. I also look at the H&P. I then start doing my care plans, which are very similar in content (apparently) to how yours is done, though the actual structure may vary a bit. When it comes time to do my Nursing diagnoses, for my rough draft, I take the above information and see how the data looks, and I look at the nursing Dx to see how it fits that data. Am I generating a nursing diagnosis from a medical diagnosis? Not directly. I look at what was involved in making that medical diagnosis, how the patient would present to the physician, and the underlying pathophysiology. I look at the signs and symptoms listed on the H&P. In short, I'm building a mental picture of how this patient should likely present to me when I see the patient the next day and my likely findings. That's what I begin doing my rough draft nursing diagnosis from.

Once I am able to assess the patient for myself, I can then look at the "current" data that I have acquired and I can then revise my nursing diagnoses based on those findings instead. Often, I'm not that far off from my 1st guess nursing diagnoses based on the previously gathered data. Just how off from reality I am really depends upon the quality of the gathered data.

In short, I'm not trying to equate medical diagnoses to nursing diagnoses, rather I look at the constellation of signs and symptoms that surround and likely surround a patient based on those medical diagnoses, current and past. Then knowing the pathophysiology behind that stuff, the likely nursing diagnoses usually become pretty clear.

I certainly admit that it's very tempting at times to try to simply equate a medical diagnosis to a nursing diagnosis directly. It just doesn't work because the two models look at the body and it's response to disease states in different ways.

[RunBabyRN]

During the first semester, we went in and "pre-labbed", where we pored through the chart and got the picture on the patient, as well as their meds (which we had to look up and make cards for). We didn't really do care plans before we saw the patients, but we did have to write a report with nursing diagnoses and write our plan of care based on those (and references).

From the second semester on, we got morning report with the nurse, and if we had time before, we got what we could on our patients.

[Esme12, ASN, BSN, RN]

You are right....you need to know and look up everything...you are learning. The when you assess that patient you change it....just like you would in actual practice.

For instance for CHF you would be thinking about what CHF is, what does is do? what symptoms could your patient have? What meds are they on? what side effects do those meds have? What should I be looking for? ...as you walk down the hallway you think of all the possible scenarios that could affect this patient. As you assess the patient you notice the are SOB at rest with crackles and an O2 sat 90% on room air, they are moist and clammy/cool....you think .....now what would you do?

There is the care plan.

here is a nice brain sheet from another member daytoite (RIP) to collect your information....Critical Thinking Flow Sheet for Nursing Students.doc

[krisiepoo]

That's exactly how my school worked until mid-2nd to last semester and the last semester when they wanted us to act like "real" nurses and do things as we came in.

Good luck :)

[bluedove1]

I'm just curious to know how other schools do their care plans. First off- I have no problem writing my care plans - but my school requires we go in the day before clinical and write down information on a pt (dx, hx, meds etc.), but we are not to meet with the patient. We then come to clinical the next morning with completed drug cards, a care plan (to be revised and followed) and a patho paper started. What baffles me is that I am to write my care plan without my initial assessment. During clinical last semester we had time to revise our care plans if they did not make sense, but I kind of feel like I was just making things up until I did my head-to-toe. After a few rotations I caught on to read the prior nurse's assessment and that certainly helped, but we really just guessed and hoped the plan fit our patient. Do other schools do care plans this way?[/quote

We take morning report with our nurse and then go meet pt and preform all task that the nurse would from 1st semester on...you have a certain number of care plans to do each semester which increases as you go through the program. We don't go in prior to clinical....when you take that morning report that is the first time you meet that pt and you only have assess to that pt record only on the day you are working with that pt so you better get all you need to do your care plan while you are with that pt...I like it cause it prepares you for what really happens as far as getting morning report, what areas you will need to focus on in your assessment, and what needs to be done for this pt at this point in their recovery

[Nurse Kyles, BSN, RN]

What you describe is pretty much how it works. At least this is how I remember nursing school. You go in and prep the day prior to give yourself some time to think it through, because you are learning. Sure, you have not met the patient, but you do have the clinical knowledge to develop a plan. When you get to real life, real time nursing, this is how it works. A nurse might prep for 10 or so minutes on all of you patients before the shift. During report a nurse is already developing these "care plans" in their head. Darn, 3+ pitting LE edema... better make sure those legs propped up. Inactive patient, unable to be anticoagulated... better make sure those SCDs are on. You get the idea. When a nurse actually goes in to do the assessment, he or she is continuously evolving the "care plan".