Care plan help

mwilliams86 · Sep 16, 2009

Nursing Diagnosis Handbook by Betty Ackley and Gail Ladwig

jmtndl · Sep 16, 2009

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

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

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

nyteshade, BSN · Sep 16, 2009

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, RN · Sep 16, 2009

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, BSN · Sep 16, 2009

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, BSN, RN · Sep 17, 2009

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

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.

achot chavi · Sep 22, 2009

Careplans can be a very important tool in managing quality nursing care for your patients, its all how you do it and how it is implemented.

When I came to this facility the NCP's were pathetic, After inservices, I made the RN's write comprehensive careplans that cover EVERYTHING and then the LPN's have to read them and do the evals every 3 months or more if necessary and update PRN. It helps with consistency in care and the nurses were suprised how much they learned by reading them.

When one family wanted to sue us after her Mother broke her leg in the shower room, and the staff claimed that the family insisted on doing all showers so they werent to blame. The only thing that served to prevent the lawsuit was that I had updated a careplan a few months before the incident and wrote, "according to family request, all showers will be done by daughter or her appointee , SW approves" It had become so everyday and ordinary that nurses didn't bother writing about it, and of course the daughter never signed for the baths.

BTW the "I" careplans sound nice too, we dont use them and I have no idea how they would do on survey.

BTW, at the survey, we got high marks and compliments on our NCP.

The NCP is not to be brushed away as unnecessary- regard it as the mark of a professionally run unit!! It is a way to take credit for what we do!!

Schmoo1022 · Sep 22, 2009

Careplans can be a very important tool in managing quality nursing care for your patients, its all how you do it and how it is implemented.
When I came to this facility the NCP's were pathetic, After inservices, I made the RN's write comprehensive careplans that cover EVERYTHING and then the LPN's have to read them and do the evals every 3 months or more if necessary and update PRN. It helps with consistency in care and the nurses were suprised how much they learned by reading them.
When one family wanted to sue us after her Mother broke her leg in the shower room, and the staff claimed that the family insisted on doing all showers so they werent to blame. The only thing that served to prevent the lawsuit was that I had updated a careplan a few months before the incident and wrote, "according to family request, all showers will be done by daughter or her appointee , SW approves" It had become so everyday and ordinary that nurses didn't bother writing about it, and of course the daughter never signed for the baths.
BTW the "I" careplans sound nice too, we dont use them and I have no idea how they would do on survey.
BTW, at the survey, we got high marks and compliments on our NCP.
The NCP is not to be brushed away as unnecessary- regard it as the mark of a professionally run unit!! It is a way to take credit for what we do!!

Thats exactly what I mean! I am going to see if I still have my care plan book from nursing school, if not I will look into getting a new one