care plans

[lifesaver252]

so i know everyone does care plans different, some use the MDS software, some use word or publisher. How do you decide what to care plan.. i know you need to care plan triggered items from the MDS but what other stuff? do you care plan every medicine, or DX, is there a basic list of things you go by? on average how many problems are on your care plans? i know some are probably longer, some shorter.. but on average, and what are some things you regularly care plan? fall risk, weightloss? also How specific are your interventions?

i have been the MDS and care plan coordinator for 5 years at an 85 bed facility. i recently left that job, and am on job number 2 since then. it has been a challenge to me to pick up on someone elses care plans, its been frustrating. my care plans on average have been about 10-12 problems.. maybe more- maybe even less.. but both facilities i have been in since then, have 20-30 problems atleast and to me it seems they are not care planning things that need to be care planned and are care planning wierd problems, with wierd goals. now im begining to question my care plan abilities, even though ive never had a problem before.

just curious about other facilities.. thanks

[katoline]

besides what triggers on the caas, we careplan anticoagulants, pacemakers, personal preference, dx related such as fluid imbalance, resp. distress, risk for infection, hypo/hyperglycemia, renal insufficiency, cardiac insufficiency etc.

[iceprincess492]

Our corporation has certain careplans they require us to do. We do everything that triggers and everyone has to have: falls, preventative skin, ADL's, toileting, pain, any actual wound, and primary dx. we also care plan anyone who is non compliant with anything....although with 3.0 has changed from "res noncompliant with....." to "Res chooses to....." :)

[Nascar nurse, ASN, RN]

20-30 problems - oh my! Someone with 20-30 different problems outta be dead! just kidding.

I agree with previous posters. Mine are generally 10-12 problems. We are switching over to I careplans. I try my best to intergrate resident preferences into the problem. Example, I am unable to complete by ADL care without staff assist. I am able to make daily decisions regarding when I want to get up, what day to bathe, etc.

Most importantly, I try really hard to not be too specific so I don't dig myself into a hole. I refuse to write "I prefer to take a shower on Tuesdays at 9am".

[lifesaver252]

thank you. this helps.