Care Plans an Exercise in FUTILITY??????

Destinystar · Jun 25, 2004

unfortunatly in california title 22 california code of regulations states in section 70215.(b) that "the lvn does not have the statutory authority to formulate a nursing diagnosis, etc". you can get this info from the cna (california nurses association) website. when i see licensed nurses both lvn & rn with anywhere from 30-60 pts. to give meds, tx, weekly charting, daily charting, etc. & with our severe staffing shortage and call offs they might have the knowledge but not the time. i would be interested in hearing from nurses from other states and how there nursing practice act treats this process. :)

ya know, you sound as if you think the lpns out there on the floor aren't able to inpput anything useful. in my experience, the lpn inputs the info and the rn goes ahead and makes it so on the care plan. after all, you really can't do it all by yourself. that means you should get help! your lpns know how to formulate a nursing diagnoses, and they surely know the pts better than you do! why are you wasting your resourses?

Destinystar · Jun 25, 2004

the care plan process is confusing to me. maybe you can clarify some issues since you have a lot of experience with them. in obra it is refered to as an interdisciplinary care plan. just states the rn must coordinate it that of course is a federal regulation. i dont know about your state but in california the state regulations (title 22) states that lvns are limited to writing whatever interventions they are responsible for on the care plan and only rn's can formulate nursing diagnoses. in spite of that it is common practice in the ltc in california for dietary supervisors, activity directors, & social service designees to be writing care plans. i mean nursing diagnoses, goals and interventions. lvn's write them to. :)

sounds like a problem specific to california (and maybe some other states as well) or specific to some facilities.
while the rap falls under the rn scope, the gathering of information does not and unless the patient has had a significant change of condition there is absolutely no reason to re-invent the wheel when doing the careplan.
i worked as the mds coordinator for the 116 ltc beds at a 160 bed facility. that works out to about 6 hours per patient per quarter.
if the charting was an accurtate reflection of what was going on with the patient (and the other disciplines did their portions on time) it was more than adequate.

ErinR · Jun 25, 2004

Ya know, you sound as if you think the LPNs out there on the floor aren't able to inpput anything useful. In my experience, the LPN inputs the info and the RN goes ahead and makes it so on the care plan. After all, you really can't do it all by yourself. That means you should GET HELP! Your LPNs know how to formulate a nursing diagnoses, and they surely know the pts better than you do! Why are you wasting your resourses?

My LPN's and RN's on the floor are scared to death of the careplans because the surveyors pick them to death and then someone gets the finger pointed at them. I don't really blame them. They are quite capable of the task, but so overloaded they don't have time. I am a part-time MDS Coordinator, CRNAC, in a small rural facility of 54 beds. I depend on the copy of the telephone order to keep up with the daily changes. My hours in the facility are based on the current number of residents in house, so I may be out of the facility for 4-5 days at a time. My floor nurses make extra notes to me on my copies of the TO that help me a lot to keep up with resident changes. I am very grateful for what they do and try to extend to them my appreciation regularly. Input from SS is another story. Like pulling teeth.

missmercy · Jun 25, 2004

Care plans are SUPPOSED to assist nurses in providing CONSISTANT care for patients across shifts, days etc...... Great idea in theory -- in practice, while they are nurse driven, independent from physicians orders and can provide specific , individualized road maps for patient care --they have become cumbersome, and often ignored. Nurses are so busy doing the tasks that we have piled on top of us that the care plan issue feel like extras. In truth, care plans outline thing we can do without haveing to wait for a doctor to get back to us, things we do not have to wait for someone else to approve prior to initiating it! They have the potential to be a great source of evidence in favor of the professional role of the nurse. I think we need to find a way to streamline care plans as a whole -- they are time-consuming. Many facilities have computer careplans that will spit out a form for the nurse based on what nsg, dx is entered -- that weems to trim some of the excess time --

Destinystar · Jun 25, 2004

you hit the nail on the head ms. mercy. we need to find a way to make the care plan process work & for it to be utilized the way it was intended.

care plans are supposed to assist nurses in providing consistant care for patients across shifts, days etc...... great idea in theory -- in practice, while they are nurse driven, independent from physicians orders and can provide specific , individualized road maps for patient care --they have become cumbersome, and often ignored. nurses are so busy doing the tasks that we have piled on top of us that the care plan issue feel like extras. in truth, care plans outline thing we can do without haveing to wait for a doctor to get back to us, things we do not have to wait for someone else to approve prior to initiating it! they have the potential to be a great source of evidence in favor of the professional role of the nurse. i think we need to find a way to streamline care plans as a whole -- they are time-consuming. many facilities have computer careplans that will spit out a form for the nurse based on what nsg, dx is entered -- that weems to trim some of the excess time --

kids · Jun 25, 2004

the care plan process is confusing to me. maybe you can clarify some issues since you have a lot of experience with them. in obra it is refered to as an interdisciplinary care plan. just states the rn must coordinate it that of course is a federal regulation. i dont know about your state but in california the state regulations (title 22) states that lvns are limited to writing whatever interventions they are responsible for on the care plan and only rn's can formulate nursing diagnoses. in spite of that it is common practice in the ltc in california for dietary supervisors, activity directors, & social service designees to be writing care plans. i mean nursing diagnoses, goals and interventions. lvn's write them to. :)

the way the rules are in interpeted in my area is that the rns signature on the mds "certifies" that the contents are complete and accurate, the rn signature on the care plan "approves" it. the rules (here) do not specify that the rn writes every word on the mds/raps/care plan, only that an rn had reveiwed the contents, made any changes and approved it.

i went thru to many state surveys before, during and after obra was implimented and 2 federal after using these methods, not once were they questioned. and yes, the state & federal surveyors were aware as it was the procedure was documented.

Destinystar · Jun 26, 2004

the ltc that i have worked in the surveyors have never commented on who wrote the care plan just on the accuracy of the information.

the way the rules are in interpeted in my area is that the rns signature on the mds "certifies" that the contents are complete and accurate, the rn signature on the care plan "approves" it. the rules (here) do not specify that the rn writes every word on the mds/raps/care plan, only that an rn had reveiwed the contents, made any changes and approved it.
i went thru to many state surveys before, during and after obra was implimented and 2 federal after using these methods, not once were they questioned. and yes, the state & federal surveyors were aware as it was the procedure was documented.

tshores · Jul 6, 2004

I don't know much about LTC, but in ICU's I've worked in (for 25+ years), most nurses record patient-specific information in a kardex or sheet of paper (or even half-sheet of paper) left on a clipboard with the nurse's notes. That is our true care plan where we write all the diagnoses, history, lab to be drawn or other procedures, any tubes or drains to suction or not, dressings, whether to crush meds--anything at all pertaining to the care of that patient, even family phone numbers. Yeah, they get kinda messy with all the updates, but they're REAL care plans and that's what we really follow. I think we should just stick the messy old ones in the chart when we make out new ones because that's what we really do for our patients.

But instead, we have a four-page NCP no one looks at (at least not for any guidance), a two-page teaching form, and a three-page admission form. Yes, we need an admission form, but we sure don't need the other forms. We should be charting our teaching anyway without a separate form. And now we have wound assessment forms and orders, restraint forms and orders, epidural forms, PCA forms, transfusion report forms, and so on. If we give blood to someone who has a PCA, we are charting VS on three different papers (including the nurse's notes). Ridiculous. I agree that NCP's are great for students, but they're an incredulous waste of time for nurses. Let's start saving our real care plans (you know, the messy but true ones) and save a lot of trees, too. :chair:

alacek · Jul 6, 2004

We utilize clinical pathways, and they are located on the opposite side of our nurses note (flowsheet). I work in OB, so most of our patients have a fairly identical and straight forward POC. There is room at the bottom to add in anything unique to each patient. I actually review mine every day, mainly because I don't work on the postpartum side very often, and I need to refresh my memory on what needs to be done. In L&D, we don't use the clinical pathways :)

Destinystar · Jul 6, 2004

I agree in the olden days the care plan was a very functional tool to pass info from shift to shift, it was written in pencil and updated with the essentials every shift for continuity of care. In LTC they have taken it to another level. It has turned into a nursing manual. Not user friendly. Put in the charts because that is what the law mandates, It is way to much information for anyone to find any practicle use for them. :uhoh3:

I don't know much about LTC, but in ICU's I've worked in (for 25+ years), most nurses record patient-specific information in a kardex or sheet of paper (or even half-sheet of paper) left on a clipboard with the nurse's notes. That is our true care plan where we write all the diagnoses, history, lab to be drawn or other procedures, any tubes or drains to suction or not, dressings, whether to crush meds--anything at all pertaining to the care of that patient, even family phone numbers. Yeah, they get kinda messy with all the updates, but they're REAL care plans and that's what we really follow. I think we should just stick the messy old ones in the chart when we make out new ones because that's what we really do for our patients.
But instead, we have a four-page NCP no one looks at (at least not for any guidance), a two-page teaching form, and a three-page admission form. Yes, we need an admission form, but we sure don't need the other forms. We should be charting our teaching anyway without a separate form. And now we have wound assessment forms and orders, restraint forms and orders, epidural forms, PCA forms, transfusion report forms, and so on. If we give blood to someone who has a PCA, we are charting VS on three different papers (including the nurse's notes). Ridiculous. I agree that NCP's are great for students, but they're an incredulous waste of time for nurses. Let's start saving our real care plans (you know, the messy but true ones) and save a lot of trees, too. :chair:

Destinystar · Jul 6, 2004

My post was geared towards LTC and the way they are used in that setting. IN LTC a nurse can easily have 60 patients. The care plans in LTC are written and utilized differently than they are in a hospital. We have elderly people with ADL defecits and several medical problems, CHF, Diabetes, Stroke, Shizophrenic, etc. The care plans for these folks look like a novel. On the other hand in your setting you are responsbible for like 2 or 4 patients that have similar problems with a few extra things here and there. And I am sure with this few you have the time to review, update and read the care plans every shift. On 60 residents with as many as 25 different problems we dont have time to review the care plans.

We utilize clinical pathways, and they are located on the opposite side of our nurses note (flowsheet). I work in OB, so most of our patients have a fairly identical and straight forward POC. There is room at the bottom to add in anything unique to each patient. I actually review mine every day, mainly because I don't work on the postpartum side very often, and I need to refresh my memory on what needs to be done. In L&D, we don't use the clinical pathways :)

bluesky, BSN, RN · Jul 6, 2004

But without careplans we wouldn't have anyplace to write the ever so helpful nursing diagnoses.

:rotfl: :rotfl: :chuckle :rotfl: