Care Plans - What's their purpose? - What do you think of them?

[jjjoy]

I saw a nursing student and her instructor reviewing a care plan today and she was reviewing something about wording of the care plan and it reminded how frustrating nursing education can be and how mixed up it can seem to be sometimes!!!

At my school, anyway, a care plan for something as post-anesthesia nausea would be grilled for the wording of the nursing diagnoses, the specific wording of the nursing interventions and goals.... to make sure that we were using impractical "nurse speak" as opposed to - oh no! - referring to a medical condition directly (eg pt constipated, possibly d/t medication side effect, keep hydrated, adm laxative as ordered, etc). Students should ideally be able to rattle off quickly the what's and why's. I think the nitpicky round-about descriptions required in nursing school make simple concepts more confusing... and end up wasting the valuable time of students.

[bcaudi01]

I think that care plans for the most part are a waste of time. As a nursing student I feel that some instructors make students spend too much time feeling out care plans which takes away from our hands on experience. My mom is a nurse and says that she does all her care plans on the computer which is much more convenient. I think we should focus less on care plans for our patients and more on actually caring for them.

[jaywife]

i think care plan is very important, we need to be familar with it

[Ace1Rnelp]

hi to each and everyone out there,

this is my very first post to this forum. i love discussions about care plans. this topic is very near and dear to my heart.:redpinkhe

here's my 10 cents about care plans.

first of all, nursing care plans are really vital to students' life and to our professional life.

why? because it is a problem-solving and critical thinking tool that helps us apply knowledge and skills to improve our clinical practice. it intensifies our professional confidence and surely improve communication with our patients and our colleagues. concerning documentation, it will aso help us document our care more precisely and ensure our actions are within national standards and legal guidelines. i could probably go on some more, but for now, i think this will suffice.

secondly, i do expect my students to do their best in the nursing care plan process.

why? this is not to mention, it can make or break their patient's life.

why? because i have to grade them and according to their syllabus, their mid-term and final evaluations are, more or less, 85% ncp process (from assessment to planning and intervention, to evaluation). so to get a better grade, their ncp should be to my standards. it gives me information on how students take care of their patients.

thirdly, my students are not on their own trying to figure out how to be really good at ncps (even though they had previous instruction about ncp).

why? because i am with them all the way. from the very start of clinical rotation (orientation day), i spend a good hour to hour and a half (or more if need be), just for discussion about care plans (includes case scenarios and practice). i also give them a packet, which includes a written instruction on how i want them to do their care plans. that way, if they have questions, they can always go back and look for answers. then, on the very first week, i give them one on one feedback when i return their papers, with my written comments in blue or green ink (not red). i do not want them to think i am screaming at them.

lastly, i pull them out for few minutes from clinical to the nurse's lounge if they are not busy and we discuss their patients. because, we might have only few minutes, i ask my students to give me their information in an adpie outline (assessment, diagnosis [nsg], planning, interventions, evaluation). if they happen to be busy, which is always the case, i do not pull them out. i want them to have the opportunity to learn hands-on as much as possible. in this case, we discuss all about their patients (includes care planning) either during pre or post conference.

this is how i do my part in order to get my students to where i want them to be. after i'm done with mine, i do expect them to do their part, as well. seeing their progression from the very start to the end of rotation (6 weeks, 2 days a week, 8 hours a day) is really an amazing feeling. i am proud of all my students and their accomplishment thus far. it is hard work (for me and for them), but it is all worth it.

i am also including the written instruction i give my students on care plan, simple and easy to understand, plus 2 samples of nursing diagnosis. i am open to suggestions and comments.

nurs 3609 / spring 2009

instructor: ___________________________

nursing care plan

reference:

kozier, b., erb, g., berman, a., & snyder, s. j. (2004). fundamentals of nursing: concepts, process, and

practice (7th edition), pp 257-327. pearson education, inc., upper saddle river, new jersey 07458.

always prioritize

nursing diagnosis:

the format will be: problem: ________________________________________________

related to (r/t): __________________________________________

as evidenced by (aeb): subjective data or symptoms - apparent only to the person affected and can

be described or verified only by that person.

example: itching, pain, feelings of worry

can also include client's sensations, values, beliefs, attitudes, and

perception of personal health status and life situation

"dad is very confused today."

objective data or signs - are seen by an observer, can be measured, or

tested against an accepted standard. they can be seen, heard, felt, or

smelled, and they are obtained by observation or physical examination

(observable and measurable).

example: a discoloration of the skin, a blood pressure reading, a wbc result

"dad couldn't remember his address or phone number today."

short-term goal: general goal is stated as the opposite of the problem and then followed by a list of observable

desired outcomes. if achieved, the outcomes would be evidence that the problem has been prevented.

goals or expected / desired outcomes usually have the following 4 components: subject, verb,

conditions or modifiers, and criterion of desired performance (date/time).

a) subject - the subject, a noun, is the client, any part of the client, or some attribute of the client, such as the client's urinary output. it is often omitted in the goals; it is assumed that the client is the subject unless indicated otherwise.

b) verb - the verb specifies an action that the client is to perform, for example, what the client is to do, learn, or experience. verbs that denote directly observable behaviors, such as administer, show, or walk must be used.

c) conditions or modifiers - conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed.

- for example:

walks with the help of a cane (how)

after attending two group diabetes classes, list signs and symptoms of diabetes of diabetes (when)

when at home, maintains weight at existing level (where)

discusses food pyramid and recommended daily servings (what)

conditions need not be included if the criterion of performance clearly indicates what is expected.

d) criterion of desired performance - the criterion indicates the standard by which a performance is

evaluated or the level at which the client will perform the specified behavior. these criteria may specify time or speed, accuracy, distance, and quality.

- examples are:

weighs 75 kg by april (time)

lists five out of six signs of diabetes (accuracy)

walks one block per day (time and distance)

administers insulin using aseptic technique (quality)

questions to ask: "how will the client look or behave if the healthy responses are achieved? (what

will i be able to see, hear, measure, palpate, smell, or otherwise observed with my senses?")

what must the client do and how well must the client do it to demonstrate problem resolution?

goals must be individualized, measurable, realistic, specific, and achieved within a given time

write at least 3 expected outcomes.

examples of measurable verbs: verbalize, state, list, demonstrate, ambulate, perform, apply, avoid,

describe, report, discuss, identify, explain, exhibit

examples of verbs to avoid: allow, know, learn, understand, have

interventions - are actions that the nurse performs to achieve client goals.

the specific interventions should focus on eliminating or reducing the etiology of the nursing diagnosis.

types: independent - actions performed by the nurse without the need of a physician's order.

example: teaching client how to cough and deep breathe

dependent - actions carried out under physician's orders or supervision.

example: administering a medication

collaborative - actions the nurse carries out in collaboration with other health team members,

such as physical therapists, social workers, dietitians

example: physical therapy to teach client crutch walking

format of written interventions is similar to that of outcomes: verb, conditions, and modifiers, plus time

element.

- examples:

explain (to the client) actions of insulin (such as .......) today at 0900 ...

measure and record ankle circumference daily at 0900...

apply spiral bandage firmly to left lower leg ...

assist client with tub bath daily at 0700 ...

administer analgesic 30 minutes prior to physical therapy ...

always include: monitor, assess, teach, other action (at least 4 interventions)

evaluation - is planned, ongoing activity in which the client and healthcare professionals (nurses) determine the client's

progress toward achievement of goals.

write: by 1300 today: goal was met aeb:

goal was not met aeb:

goal was partially met aeb:

nursing care plan / example

# 1

nursing diagnosis: ineffective airway clearance r/t viscous secretions and shallow chest expansion

aeb: objective data: pallor and cyanosis to skin and mucous membranes, incorrect use of breathing

and coughing techniques, rr at 26-30/min., o2 sat. at 79% on ra

subjective data: "i am very short of breath."

stg: the client will have effective airway clearance by 1300 today aeb:

1. absence of pallor and cyanosis to skin and mucous membranes

2. will demonstrate correct use of breathing and coughing techniques after instruction

3. absence of shortness of breathe, rr between 16-24/min., and o2 saturation above 92%

interventions: the nurse will:

assess respiratory status every 4 hrs.: rate, depth, effort, skin color, mucous membranes, amount, and

color of sputum (detect early signs of compromise and allow for prompt intervention

[canale/ulrich, 13]).

monitor level of consciousness q 4hs. and as needed (same as above)

teach breathing and coughing techniques, remind to perform every 3 hours (deep breathing help

clear the airways by loosening secretions and promoting a more effective cough).

auscultate lung sounds every 4 hours and as needed (same as above)

administer oxygen by nasal cannula as prescribed (help relieve respiratory distress [taylor, 34])

evaluation: goals met: by 1300 today:

client has no pallor and cyanosis to skin and mucous membranes.

client demonstrated correct use of breathing and coughing techniques after instruction.

client has no shortness of breathe, rr at 20-22/min., 02 sat. at 92-94% on 2l nc of o2.

nursing diagnosis: acute pain r/t tissue trauma and reflex muscle spasms associated with the surgery

aeb: objective data: positive guarding during ambulation and when moving on bed

bp - 130/79, hr - 102/min.

subjective data: patient has c/o pain - at 7 on a scale of 0-10

requests pain medications every 2 hours

stg: the client will have absence of pain or decreased pain level by 1300 today, aeb:

1. relaxed facial expression with less evidence of guarding during ambulation and when moving on bed

2. bp will be less than 120/75, hr will be less than 100/min.

3. will rate pain at or below 4 on a scale of 0-10

4. decreased request for pain medications to every 6 hours

interventions: the nurse will:

assess for signs and symptoms of pain (e.g., verbalization of pain, grimacing, reluctance to move,

increased bp and tachycardia) q 4 hrs. and as needed (allows for prompt intervention and improved

pain control [canale/ulrich, 46]).

monitor vs every 4 hours and as needed (to detect early signs of compromise [taylor, 34]).

teach non-pharmacologic methods for pain relief today at 1000 (e.g., position change, restful

environment, relaxation exercises) (it is believed that most non-pharmacologic interventions are

effective because they stimulate closure of the gating mechanism in the spinal cord and

subsequently block the transmission of pain impulses. they also help decrease pain by

promoting relaxation[canale/ulrich, 46]).

administer analgesics before activities and procedures that can cause pain and before pain becomes

severe as needed(mild to moderate pain is controlled more quickly and effectively than

severe pain [canale/ulrich, 34]).

instruct client to support abdominal incision with a pillow or hands when turning, coughing, or deep

breathing (reduces muscle tension)

evaluation: goals partially met by 1300 today:

client rates pain at 5 on a scale of 0-10

client remains with positive guarding on movement

client requesting pain medications every 4 hours

bp - 120/75, hr - 100

i am not sure, how the posting will turn out, but guess have to wait and see. in addtition, if the goals are not met, then they have to state why and what interventions nd the like they have to do (again) to address the unmet goals.

whew!!! this is the longest ten cents of my life.

[Ace1Rnelp]

It's me again.

I forgot to add, so far, I have received positive feedback from my students. How do I know? I make sure they filll up evaluation form that I had created for myself, on their last day.That way, I can keep strategies that work for me and my students and make changes if they don't. As far as the school, it is always positive as well, and really good evaluations (of me) from our course coordinator. Thanks...

[lasie2005]

THANK YOU

Gahhhhh! Nursing instructor here- Please don't flame me! :sofahider

And sorry my post is long- I'm going to try to give you the rationales of why teachers do what they do.

And I'm not an old one either, I graduated from nursing school in the early part of the 2000's, and hated doing careplans then. Didn't really get the point until I was an RN and in grad school.

And I do not waste time during clinical going over them. The students need to care for their patients! The only time I will review a careplan is if I get the feeling during report that the students didn't know what the heck was going on with their pt, then I will take them aside and try to determine if they don't know what is going on because they didn't pre-plan well (which may result in going home) or if they had a weird/ difficult pt (which will not result in going home).

One of the main reasons schools use careplans (other than it being a nursing thing) is so students can learn the material. So when you become an RN you will be able to rattle off some E0's and interventions (along with knowing why you are doing them) in your head when you get that new admit.

And for the most part RN's do not use careplans a whole lot doing day to day work, but that is because they have already internalized the information and proven their knowledge to the state board and a college (which resulted in the form of a degree). Formed care plans are a set and organized way for students to show me how much they know so I don't have to pimp them the entire time of clinical. I can leave them alone so they can do their work. My husband is an engineer, and during school he had to write a load of lab reports. He NEVER has to do this now, but he did it then to show the professor that he actually learned something and could advance in the course. Careplans are pretty much the same thing (to me anyway).

Here is what I expect (and why). I teach peds clinical, so some things are different. And for me, if a student copies a careplan straight out of a book, they are most likely going to get it wrong, because the books can't individualize care for a pt. All pt/families are different, so a care plan is individualized to the pt you are caring for.

I want my students to write every possible, actual or risk for dx, because I want them to look at their pt as a whole, see how one disease process can have an effect on many areas, and be able to recognize potential problems so they can intervene before it become actual- if possible.

Nursing dx: After the R/T I expect to see WHY or HOW ( such as pathologically- what is going on). For example, if it is an open appy who is on morphine. I don't want to see Constipation R/T morphine use. I want to see Constipation R/T decreased intestinal motility due to use of morphine for pain. I never want to see a medical dx, because it doesn't explain the patho. And the AEB should be physical assessment findings, labs, or pt statements that back up the use of the dx.

Why am so picky about this? Because I am eternally suprised that many nursing students are so poor in patho. How can you know what problems to expect if you don't know how and why the body is going to respond to certain diseases/meds? How are you going to explain a process you don't undertstant to a parent or patient? And I want to make sure you are doing good assessment techniques even when I am not around to watch.

Expected outcomes: I want these to be measurable and specific to the pt. I teach peds, and we get all shapes and sizes. So I want to make sure that the student knows what is normal (and what isn't) for each of the age groups we will take care of. I want it to be measurable so that we can have a black and white way to to determine if the goal was met. I started being more strict on this when I discovered that many students didn't know normal Pulse, Resp, B/P for the different age groups they were going to take care of, as well as what pain scale to use with what child. Or what to expect from which age groups.

Interventions/Rational: This is so I know that you know what you should be doing during clinical as well as a way for me to see what kind of knowledge you have as far as a child's growth and development. I once had a student write an intervention for cough and deep breathe for a newborn. Now, HOW are you going to do that?:smackingf

Yes, I hate grading paperwork during my weekend "off." But I know that it does actually have a point and that it can provide a different type of instruction. Sometimes I feel like this because I'm just not getting through. But usually I feel like this :loveya: because at some point it all clicks in their head. That is when they start to think like nurses, and I love it!

And my students must too because on ratemyprofessor, I have great positive comments. I love checking in there to see what my students write!

Ok, sorry to be so long, but this is the type of thing that gets my panties in a wad!

Don't flame me too hard! :wink2:

[jlynn2303]

Hi, This is my second quarter in nursing school, and I absolutely hate care plans. It feels like it has been one long guessing game as to what the prof wants - partially bc the first one was really laid back, and this one isn't, and what was fine last term is terrible this term? How was I supposed to know this?

I think some of my biggest problem with this is 1. What's the point? If I am monitoring, say, K if they are receiving diuretics, so what? I can't do anything about it. I think that's a huge part of my problem, is that it seems like trying to pretend we have more power or authority than we do, like some sort of game. What does it matter if I see all this stuff - it's in the med record, the doctor knows, and I'm not allowed to do anything about it - order meds or electrolytes or whatever. 2. It seems like most of the time what I end up dealing with has little or nothing to do with the admitting dx, i.e. a lady came in bc she choked on a piece of ham. Well, once that was out, she just hung out for a day or two til they could get her back to the nursing home. So, I'm looking for stuff to try and come up with a care plan. Some of it is stuff we say over and over (i.e. breathing, etc) and it's just standard. 3. I only see these people for one day. How in the world am I supposed to write a realistic goal, and how/when it will be realized, if I will only see them for one day, and actually have absolutely no idea how any of these things will turn out? Especially when I was in trauma, people were in and out quickly. Risk for impaired skin integrity - ok, I've got 6 hours and I'll never see them again. What is there, really, besides basic care? (i.e. clean, protect the skin, etc)

It feels like this entire experience has been one long guessing game, and a very frustrating one - and I am not the only one in my class who is having this much trouble. We only get six clinical days this term, and it seems like I've been trying to figure it out. I turn it in, she hands it back ripped up. Ok, fine, what can I do but try again next time? So, I do it, and another week goes by. It's not like I have no experience with school, as I have an advanced degree in another field, but I am beginning to see wht they mean by nurses eat their young.

If I have no authority to actually DO anything about the problem, and the lab results are in the computer, and the doctor knows ( or should if the record is read) what is going on, (i.e. anemia, or low Hct/Hg) and I'm not allowed to do anything about it - how and WHY write a care plan about it? It seems like a game of pretend.

Help? Hope? Explanation?

[Daytonite, BSN, RN]

hi, this is my second quarter in nursing school, and i absolutely hate care plans. it feels like it has been one long guessing game as to what the prof wants - partially bc the first one was really laid back, and this one isn't, and what was fine last term is terrible this term? how was i supposed to know this?

i think some of my biggest problem with this is 1. what's the point? if i am monitoring, say, k if they are receiving diuretics, so what? i can't do anything about it. i think that's a huge part of my problem, is that it seems like trying to pretend we have more power or authority than we do, like some sort of game. what does it matter if i see all this stuff - it's in the med record, the doctor knows, and i'm not allowed to do anything about it - order meds or electrolytes or whatever. 2. it seems like most of the time what i end up dealing with has little or nothing to do with the admitting dx, i.e. a lady came in bc she choked on a piece of ham. well, once that was out, she just hung out for a day or two til they could get her back to the nursing home. so, i'm looking for stuff to try and come up with a care plan. some of it is stuff we say over and over (i.e. breathing, etc) and it's just standard. 3. i only see these people for one day. how in the world am i supposed to write a realistic goal, and how/when it will be realized, if i will only see them for one day, and actually have absolutely no idea how any of these things will turn out? especially when i was in trauma, people were in and out quickly. risk for impaired skin integrity - ok, i've got 6 hours and i'll never see them again. what is there, really, besides basic care? (i.e. clean, protect the skin, etc)

it feels like this entire experience has been one long guessing game, and a very frustrating one - and i am not the only one in my class who is having this much trouble. we only get six clinical days this term, and it seems like i've been trying to figure it out. i turn it in, she hands it back ripped up. ok, fine, what can i do but try again next time? so, i do it, and another week goes by. it's not like i have no experience with school, as i have an advanced degree in another field, but i am beginning to see wht they mean by nurses eat their young.

if i have no authority to actually do anything about the problem, and the lab results are in the computer, and the doctor knows ( or should if the record is read) what is going on, (i.e. anemia, or low hct/hg) and i'm not allowed to do anything about it - how and why write a care plan about it? it seems like a game of pretend.

help? hope? explanation?

i think you are missing the point of nursing school. you are supposed to be learning about nursing and what nursing problems are--not riding on the coattails of doctors and following their medical diagnoses. oh, that information is important to know. the reason you took all those pre-requisite classes was so you could understand what the doctors are doing. however, in addition to assisting physicians we nurses do our own thing independent of what the doctors do. you are absolutely wrong when you say that you "have no authority to actually do anything about the [nursing] problem". i guess it all depends on what your definition is of what doing something about the problem is. we have no authority to do anything about the medical problem. however, we have a great deal of authority to do something about the nursing problems. so much authority that the doctors cannot legally interfere with our independent nursing interventions. first, however, you must learn to distinguish between a medical problem and a nursing problem. there is a range of 4 types of things we can do for any nursing problem:

• assess/monitor/evaluate/observe (to evaluate the patient's condition)
  
• care/perform/provide/assist (performing actual patient care)
  
• teach/educate/instruct/supervise (educating patient or caregiver)
  
• manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
  

you will find the ones appropriate to each nursing problem you are addressing in your nursing textbooks. perhaps you have just been looking in the wrong places.

if you are monitoring k+ because the patient is receiving diuretics, what you can do about it if the k+ becomes abnormal is to assess the patient for any physical manifestations and notify the physician of the situation, remind him what diuretic the patient is getting, how much k+ is or isn't in the patient's iv fluids and request orders appropriate to the situation. that's what you are allowed to do about it. the rationale for doing that is because early detection of electrolyte imbalances allows for quick correction of any deficits. if you were not there to do this monitoring and management, the doctor would not be aware of any problem until he makes his next rounds of his hospitalized patients which could not be for many, many hours.

it seems like most of the time what i end up dealing with has little or nothing to do with the admitting dx, i.e. a lady came in bc she choked on a piece of ham. well, once that was out, she just hung out for a day or two til they could get her back to the nursing home. so, i'm looking for stuff to try and come up with a care plan. some of it is stuff we say over and over (i.e. breathing, etc) and it's just standard.

an admitting diagnosis is a medical problem. if this lady was in a nursing home, she was there for

nursing

care. i worked in nursing homes periodically throughout my career. while she was "hanging out for a day or two" until she got taken back to the nursing home, it would have been totally appropriate for you to do nursing care for her. i guarantee that the nursing home has a complete written plan of care for her based on an

assessment of her adls

(activities of daily living) and what nursing assistance she needs to accomplish them. i wrote hundreds of care plans for patients residing in nursing homes i worked in. she may have clear lungs, but if she needs help pottying, taking a bath, cleaning her teeth or cutting up her food, those are

nursing problems

known as self-care deficits (in nanda language).

i only see these people for one day. how in the world am i supposed to write a realistic goal, and how/when it will be realized, if i will only see them for one day, and actually have absolutely no idea how any of these things will turn out?

i've addressed goals before in my posts. goals fall under step #3 of the nursing process when you are writing a care plan. goals, in essence, are the predicted results of your planned nursing actions. experience and knowledge are how you determine when a goal will be realized. sometimes knowing the pathophysiology of a medical disease is helpful when predicting goals for the physiological nursing diagnoses. reading and studying about what you are ordering for someone is also something that you should do. you shouldn't be ordering things for patients (i'm talking about nursing interventions) if you don't understand and know what effect they are going to have on someone. that is part of your responsibility as a professional nurse. that is why you are supposed to learn about the side effects and complications of all your nursing actions. side effects, complications and predicted results of action aren't specific to administration of medication or insertion of some piece of equipment in a patient's body. every action has consequences and reactions and you need to find out what they are when you order them for patients.

risk for impaired skin integrity

"risk for" diagnoses are anticipated problems--nursing problems that do not yet exist. the goal, very appropriately, is that the skin will remain intact or some version of that statement worded in a similar manner. interventions for the "risk for" nursing diagnoses are limited to:

• strategies to prevent the problem from happening in the first place
  
  
• monitoring for the specific signs and symptoms of this problem
  
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  
  

it feels like this entire experience has been one long guessing game, and a very frustrating one - and i am not the only one in my class who is having this much trouble. . .it seems like i've been trying to figure it out. i turn it in, she hands it back ripped up. ok, fine, what can i do but try again next time?

i help students with care plans all the time here on allnurses. i try to put things in as simple a language as i can to help people understand how the nursing process works. i can see the frustrations you are having. you can see examples of care plan construction on this thread:

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

-

help with care plans.

if you want help with diagnosing or writing goals, post them in a thread and i will respond. or, do a search of allnurses and you will probably find a previous care plan thread that i have answered pertaining to something you are currently working on.

care planning is merely the identification of a patient's nursing problems and then the strategies to do something about them. we use the nursing process which is a problem solving method to assist us in doing that. critical thinking is the name that we throw around for this problem solving method we use. when the steps of the nursing process are followed in their correct sequence we are thinking critically, or rationally. you

can

learn this process. it takes some time and experience to get used to it, but rome wasn't built in a day. how long did it take you to learn to tie your shoes? become an excellent driver of your car? how can you expect to be a master at care planning without practice? i didn't figure out care plans and the nursing process until well after i graduated from nursing school and one day the light bulb turned on in my brain, so have some faith in yourself.

albert einstein said:

it's not that i'm so smart, it's just that i stay with problems longer.

[johnemmons]

Yea, use of the proper medical jargon can get really annoying..at least from my instructor. She takes us off the floor for an hour to go over our care plans and how wrong they are and changes the wording around. I write exactly what my care plan book says and she marks it wrong!! So frustrating knowing a book is still not right for her!

She probably isn't going by the book much. When your in a hospital, i'm sure they all don't go by the book. She's just giving you pointers that will better help your career. Don't think of this as school! It's job training pretty much, enjoy it and learn all you can. It'll carry with you the rest of your life. Good lucky you'll do great.

[jjjoy, LPN]

Experience and knowledge are how you determine when a goal will be realized.

Unfortunately, some instructors evaluate a student's care plan as if the student should ALREADY have the experience and knowledge of an experienced nurse (when I say knowledge, I mean the type of knowing involved in things like "knowing how to drive a car" as opposed to having read a manual & passed a written test about how to drive a car). Some also evaluate the care plan as if the student should already have mastered how to write care plans that this instructor deems good enough when in fact the student's previous instructors may have had a very different approach to teaching & evaluating care plans and so students are practically starting all over again with each instructor.

Many instructors do a good job at using care plans as a teaching tool. Unfortunately, many others do not do a good job at using care plans as a teaching tool. Some do not make it clear what they are looking for and then rip apart whatever the student has turned in, either implicitly or explicitly communicating that such problems on the care plan may be indicating that the student is either stupid or lazy or just "not nursing material"... as opposed to being a smart, hard-working student who is right where they should be in the learning process. I'm sure that some students' care plans ARE *that* bad. But I'm also sure that some ripped apart care plans were pretty darn good given the vague requirements, lack of experience, and short time that the students may be working with.

Again, I think care plans are a great tool. I don't think that the current method of care planning that most nursing schools teach is very effective nor consistent between instructors - though certainly some instructors have developed very useful ways of teaching and using care plans. Nursing school crams a lot into a short time. My experience with student care planning included a lot of redundency that involved basic nursing care (ADLs, skin care, minimizing the risk for DVTs, falls, etc) as well as a ton of time spent on re-wording things over and over to fit each instructior's varying & often vague expectations. The former is important but there's a lot more to learn to be a well-prepared graduate. That latter could be addressed with more consistency & standardization. But the reality in too many places, it seems, is that student care plan expectations are inconsistent and at times too far removed from the experience that student nurses are having both in clinicals and in the classrooom.

[beatricejones]

I agree with many students that the care plans jargon does tend to get over the top. But i would no day want it evicted because it lends a universality to our work. It propels uniformity that allows a nurse anywhere in the world to understand the necessary data. Moreover, i guess it's this jargon that allows me, a student of an Ontario nursing program, to share opinions with nurses from different corners. :)

[Joe N635DC]

gahhhhh! nursing instructor here- please don't flame me! :sofahider

and sorry my post is long- i'm going to try to give you the rationales of why teachers do what they do.

and i'm not an old one either, i graduated from nursing school in the early part of the 2000's, and hated doing careplans then. didn't really get the point until i was an rn and in grad school.

and i do not waste time during clinical going over them. the students need to care for their patients! the only time i will review a careplan is if i get the feeling during report that the students didn't know what the heck was going on with their pt, then i will take them aside and try to determine if they don't know what is going on because they didn't pre-plan well (which may result in going home) or if they had a weird/ difficult pt (which will not result in going home).

one of the main reasons schools use careplans (other than it being a nursing thing) is so students can learn the material. so when you become an rn you will be able to rattle off some e0's and interventions (along with knowing why you are doing them) in your head when you get that new admit.

and for the most part rn's do not use careplans a whole lot doing day to day work, but that is because they have already internalized the information and proven their knowledge to the state board and a college (which resulted in the form of a degree). formed care plans are a set and organized way for students to show me how much they know so i don't have to pimp them the entire time of clinical. i can leave them alone so they can do their work. my husband is an engineer, and during school he had to write a load of lab reports. he never has to do this now, but he did it then to show the professor that he actually learned something and could advance in the course. careplans are pretty much the same thing (to me anyway).

here is what i expect (and why). i teach peds clinical, so some things are different. and for me, if a student copies a careplan straight out of a book, they are most likely going to get it wrong, because the books can't individualize care for a pt. all pt/families are different, so a care plan is individualized to the pt you are caring for.

i want my students to write every possible, actual or risk for dx, because i want them to look at their pt as a whole, see how one disease process can have an effect on many areas, and be able to recognize potential problems so they can intervene before it become actual- if possible.

nursing dx: after the r/t i expect to see why or how ( such as pathologically- what is going on). for example, if it is an open appy who is on morphine. i don't want to see constipation r/t morphine use. i want to see constipation r/t decreased intestinal motility due to use of morphine for pain. i never want to see a medical dx, because it doesn't explain the patho. and the aeb should be physical assessment findings, labs, or pt statements that back up the use of the dx.

why am so picky about this? because i am eternally suprised that many nursing students are so poor in patho. how can you know what problems to expect if you don't know how and why the body is going to respond to certain diseases/meds? how are you going to explain a process you don't undertstant to a parent or patient? and i want to make sure you are doing good assessment techniques even when i am not around to watch.

expected outcomes: i want these to be measurable and specific to the pt. i teach peds, and we get all shapes and sizes. so i want to make sure that the student knows what is normal (and what isn't) for each of the age groups we will take care of. i want it to be measurable so that we can have a black and white way to to determine if the goal was met. i started being more strict on this when i discovered that many students didn't know normal pulse, resp, b/p for the different age groups they were going to take care of, as well as what pain scale to use with what child. or what to expect from which age groups.

interventions/rational: this is so i know that you know what you should be doing during clinical as well as a way for me to see what kind of knowledge you have as far as a child's growth and development. i once had a student write an intervention for cough and deep breathe for a newborn. now, how are you going to do that?:smackingf

yes, i hate grading paperwork during my weekend "off." but i know that it does actually have a point and that it can provide a different type of instruction. sometimes i feel like this because i'm just not getting through. but usually i feel like this :loveya: because at some point it all clicks in their head. that is when they start to think like nurses, and i love it!

and my students must too because on ratemyprofessor, i have great positive comments. i love checking in there to see what my students write!

ok, sorry to be so long, but this is the type of thing that gets my panties in a wad!

don't flame me too hard! :wink2:

i'm not going to flame you for the long post. instead i am going to thank you for going into detail about what you expect.

on the other hand there are some nursing instructors out there that aren’t happy unless you copy the textbook into the care plan paper. you students know what i mean. i am all for learning the process and the patho but let’s be reasonable here. i have had complicated patients that were somewhat easy in terms of having enough material to fill it out edge to edge. on the other hand i have had quite simple patients that did not warrant the need to attempt to print in size 6 font to fit it all in. sometimes there is a space on the paper designated for "this" or "that" and there just isn’t enough information that was relevant to the patient to fill the space completely (short of making things up for the sake of having a plan look more detailed). a particular instructor rode my you know what once for not having enough on there. how can there be if the patient doesn’t have it going on? it pretty much felt like this instructor just wanted me to start making stuff up just so that she could keep me busy writing it all down, meanwhile driving me to the point of madness.

what gives?

are care plans a pain in the butt? sure, at least i think so. useful? yes, they have thier purpose. on the flipside, do the instructors have to slave drive you to the point of half-truths, just to have a plan so chock full of text that it might qualify as a textbook?

[Multicollinearity, BSN, RN]

Some also evaluate the care plan as if the student should already have mastered how to write care plans that this instructor deems good enough when in fact the student's previous instructors may have had a very different approach to teaching & evaluating care plans and so students are practically starting all over again with each instructor.

...as well as a ton of time spent on re-wording things over and over to fit each instructior's varying & often vague expectations. The former is important but there's a lot more to learn to be a well-prepared graduate. That latter could be addressed with more consistency & standardization.

I completely agree. Each semester I have to relearn how to do care-plans for each clinical instructor. There is very little standardization; it's not a matter of higher demands as the semesters progress. It's about instructors having markedly different demands and preferences for care-plans. It also lends to picking, picking, picking, and not so much learning. Last semester I overheard an instructor literally spend 20 minutes discussing how to phrase something in a student's care-plan that had nothing to do with grammar, context, content, or format. Just picking, picking, picking on word choice. Seriously. Really.

And then a couple semesters ago I had to rewrite a 20-ish page care-plan because my clinical instructor said there is no such thing as "breakthrough pain." She claimed she had never heard of the term "breakthrough pain," and it was not OK to use that term in a care-plan on a patient with pain-management problems. (I mentioned "breakthrough pain" in the care-plan body, and not in the diagnosis - I used an official NANDA diagnosis.)

I confess I wondered how long it's been since that clinical instructor worked at the bedside. She's the same one who made us z-track insulin because it seemed like a nifty idea to her.

For another instructor, we had to have specific dates in our outcome statements. For another, it was prohibited. Rewrites for everyone, everyone's care-plans rejected. And yet another instructor required three-part risk/for diagnoses. We didn't know that until we all had to redo our care-plans.

That said, I do understand the need for care-plans. They are useful for teaching students the nursing process, how to think in nursing, standardized language, and for some regulatory agencies requirements. I get all that. It's the lack of consistency and excessive care-plan 'picking' in nursing school that I hate.