Care plan question

[glm777, BSN, RN]

We have recently started using a computer system for our resident care plans. In my "paper" experience, I have always felt that less is best so our care plan were on the simple side:

Meds a/o - assess effect and side effects of meds

V/S a/o

Goal: resident will continue to asssit with self feeding through next review date

Problem: Resident has dx of PVD

But these computer care plans are outragous! The interventions include policy, the goals are so involved and the problem is so explicit!

Here are some examples:

1.Follow physician order for anti-psychotic medication administration (duh - no kidding). Document behaviors - screaming, hitting, verbal abuse and report any occurances to the MD (why? the doc knows - that's why the resident is on the ned). Observe for s/e - dizziness, lethargy, somnulence, mania, changes in mental status, decline in self care ability, increased behaviors such as rummaging through others' things, hitting, scratching, disrobing in public, smearing feces, decreased mood, abnormal labs... (let's add every other possible s/e from the packaging and see if we can hit 100 pages in the resident care plan). Complete AIMS every quarter. Attempt gradual dose reduction every 6 motnhs (some residents have rsk vs. benefits documentation to NOT decreased dose )

2.B/P, pulse, temp and respirations every shift (we don't do vitals every shift on every resident)- report DBP greater than 78 (often a norm for our residents), temp greater than 99.4(in summer it gets pretty hot here) ,pulse greater than 100 and respirations greater than 24(not unusual for our COPD patients)

3. Goal: staff will supply resident with needed care daily and will be clean, dry and odor free (OMG! not a goal - a given!)

4. Resident has dx of PVD r/t (how do I know what his PVD is related to?? Believe it or not one of the choices is "poor lifestyle choices"! Yeah I want to put that on my care plan for the state to see!!!)

I feel that these types of entries are just a tag waiting to happen! I feel that these entries speak more to policy and procedure rather than to the resident. It seems that they want to instruct nursing in nursing care 101 via the care planby including every action that nursing needs to take in dealing with each problem! What do you all think?

[toomuchbaloney]

I think that you should be able to customize the POC to the patient removing and adding problems, interventions, and goals.

[Nativejenny]

I feel your pain. I had a state surveyor look me in the eye and say "if your care plans weren't so detailed, we couldn't have picked them apart for discrepancies." She suggested "pain med as ordered" vs Duragesic patch etc... She also said "your care plans should be generically specific" whatever that means. Our administrator believes more is better, therefore, I am in the process of revamping all of our care plans. It made it a little easier to create templates. Once again I feel your pain.