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.

[BBFRN, BSN, PhD]

Your instructors shouldn't really be disagreeing that much on the wording. If you remember the 3 Ns (NIC, NOC, & NANDA), which contain the standardized language used in care plans, you should be fine. Do you have a NANDA care plan book? If so, go by that, and everything should fall into place.

I do agree that care plan language is too passive, and that a more direct way of documenting would be beneficial to nurses, though.

[crunchymomx3]

I hated writing careplans during school but just the fact of writing and having to think about how I was caring for a patient led to critical thinking. Looking back, as much of a pain as they are, they are what's needed in school.

Oh, and I went to an ASN program and we were grilled on our careplan writing more than some of the BSN students that I've met. But we had an instructor whose love in life is documentation. She wrote a book on it. lol

[Daytonite, BSN, RN]

I do think the basic concept of a care plan is valuable.

The problem is I think you are still struggling with understanding what the basic concept of a care plan is. Care planning is written documentation of critical thinking and problem solving. Care planning is the scientific process adapted to our nursing profession. Nursing imposes some specific requirements to be employed at each step of the process and that is what you seem to get hung up on. Know the process and the rules and you can employ any set of tools you are given to work with.

[NRSKarenRN, BSN, RN]

Great advice needs to be acknowledged ...and stickied in the student forum!

Also see: Help with Care Plans thread

[jjjoy, LPN]

My little rant was about how, at least in my experience as a student (not very recent by the way), the particular way care plans had to be written didn't seem the most effective way of our spending very limited time in nursing school. And I'm referring the cumbersome wording required and redundancy of basic info, not to the overall structure of ADPIE, which is a very useful method of organizing information and problem-solving.

Here's an example (probably not very good since I've been out of school quite some time now)... Let's say there's a post-op hip replacement who needs assistance getting up because they can't put full weight on their operated hip d/t avoiding full pressure on the operated hip until it's had time to heal more. They are also in pain and recovering from anesthesia. The student, however, must carefully choose their words... limited mobility r/t hip surgery... no, can't say that... limited mobility r/t impaired body mechanics d/t hip surgery??... Pain r/t surgical incision... no, can't say that...

Identifying, monitoring for, and taking steps to prevent complications is another important aspect of nursing care that seemed to unnecessarily draw out the learning process. It doesn't take long to understand and remember what types of patients are at risk for skin breakdown. I don't think having to write "at risk for altered skin integrity d/t X; check pressure points for redness (rationale ABC reference XYZ), turn patient q2 hours (rationale ABC, reference XYZ), etc)" over and over on countless care plans for two years was the only way I'd remember all risk factors for and methods of preventing skin breakdown.

[Daytonite, BSN, RN]

You weren't following the rules of NANDA which is why you were getting dinged. Sounds like you never understood what the idea was behind the structure of the PES structure of a nursing diagnostic statement to begin with. It had nothing to do with the "language" you were using, but the way you were applying the NANDA related factors for limited mobility. Risk of altered skin integrity is an anticipated problem and includes the monitoring of symptoms of it as well as strategies to prevent it from happening. That's the rule connected with developing interventions for an anticipated problem. That has nothing to do with rules of grammar and language.

I'm curious as to why this is such a concern to you now that you are no longer in school. Has it become an issue again?

[jjjoy, LPN]

Student care plans are not a direct concern to me at this time. I just saw a student and instructor the other day in the hall discussing how to word something in the care plan they were reviewing and it reminded me of the frustrations of student care plans. Not that we had to write them but that what exactly was required for them didn't seem the most effective way to cover content. They did reinforce the nursing process, as they should, it just seemed there could be a more effective way of writing and using them.

I simply have an interest in education and have taught non-nursing subjects in the past. Nursing is such an important profession and there's so much to cover in so little time in school and sometimes I imagine how my own education at the very least might have been done differently since I felt that we learned more about how to write care plans just so than about how to function as a nurse - that is how to implement the plans and to reach the goals.

[AOx1]

I am also an instructor, and my thoughts on care plans are as follows.

1) NCLEX doesn't test on NANDA terminology. NCLEX questions are developed by reviewing new graduate practice (what new grads are actually doing in the first 6 months of practice), and since NCLEX finds that new grads are not using this terminology word-per-word in practice, neither do I. My students are to explain the problem in plain english, with a focus on understanding pathophysiology and nursing care.

2) If I am a patient, and not breathing well, I don't care if my nurse knows whether it is ineffective airway clearance or ineffective gas exchange, I just want him or her to recognize an emergency and take the needed steps (O2, positioning, call for help, etc) that I need them to take so I can live. There is a lot of new literature on new grads and failure to rescue. I don't EVER want my students to be unable to recognize an emergency because they spent 8 hrs a day gathering information and not actually caring for the patient.

3) So.....what do I do instead? I have students give brief oral care plans about their patients, and I ask questions. Not just knowledge based questions like "What is vtach?" but "What would you do if you found a patient with this rhythm? What would your first intervention be?" After all, if the nurse recognizes vtach, only to go sit at the nurses' station and drink coffee, that recognition of a fact is useless.

I want any grad coming through my courses to KNOW that they can apply the standards of safe care and make quick decisions. Research tells us that in rescue/emergency situations, the nurse typically makes a decision within 30-60 seconds. I want my students to think like a nurse! They also make rounds. I have them gather assessment data with another student, and they compare notes. What is the most important care for the patient right now? I've found that the old standard care plans only tell me what you COULD do, not what you are actually doing. Most students copy out of a book. I am not interested in how well my students can copy from a book, I want to know how they think. I am also right in there with the students. If the patient vomits, I am there to help clean it up, as well as to ask the student what should we do now to help them out? There are so many other assignments my students do (brief concept maps, acting as lead nurse, conference presentations, etc.) I also have them practice giving and receiving report and "calling the doctor," which I never got a chance to practice while in school.

4) I also care about my students' well-being. I wouldn't feel safe caring for a patient on 2 hours of sleep and I am an experienced nurse. There is no way I would ever ask a new student to assume care for a patient, knowing that he or she had been up most of the night preparing care plans for my class. How can I tell them to lead a balanced life if I don't model one, and make my expectations reasonable? When the do a care plan for me, it is done "on the spot"- right then and there, either a 5 minute care plan that is oral or written. I don't belittle them if they or wrong, or hover over them while they write. I just try to redirect them with questions if they are off-target. Students are the future of nursing. I have made a committment to treat them as such, and not burn them out before they ever begin to practice. So many new grads quit in the first year of nursing. I think it's because they are so unprepared for the realities of nursing as it is. We don't do them any favors by having them complete 5 care plans per rotation with 15-20 pages each.

[Luptyloo]

This is an awesome thread! Scribble and Daytonite, your comments are very informative and helpful! I hope to have teachers like you two who will give an indication not just how to do something, but what they want me to learn from it. I enter nursing school this year and really appreciate the foreknowledge of the tool that care plan writing is. Daytonite, your mention of problem solving and critical thinking will help me approach them from that angle and hopefully learn more from them!

[jjjoy, LPN]

LiveToLearn, I like your approach. I had exactly two clinical instructors that were more focused on the actual practice of nursing as opposed to the theoretical practice of nursing, if that makes sense. They were part-time instructors who were still working and seemed to have a better sense of what new grads would need to prepared for. Some of the full-time, tenured professors seemed less comfortable in the clinical environment, emphasizing perfectionistic technique and procedure that often conflicted with what we saw the staff doing in practice (and addressed this by simply reminding us that we should always do things the right way no matter what we see other nurses doing).

Lectures were mostly straight coverage of textbook content without time for more than just the quickest of questions due to the need to cover so much material. And test questions were written trying to reflect NCLEX style questions, and thus had barely any relationship to textbook/lecture content (and never time to thoroughly review tests after we took them).

And finally, care plans. Ours were to reflect those standard care plans that you note - lots of potential nursing actions, but little application to any one particular patient... which makes sense. A formal care plan addresses all of the potential issues. It's a good exercise for class. But that's not as effective for the patient you are responsible for right here and right now, when you don't have time to review several references. You need to be able to do a quick assessment, prioritize their needs (in conjunction with other patient needs), and be ready to recognize a crisis and take action.

Instead of teaching bedbaths and transfers at the beginning, then easing into wound care and bandages... I think they should teach basic emergency care first off... what do you do if you find an unresponsive patient in the bed? Honestly, we had early ambulation, turn q2, encourage fluids (where appropriate) pounded into our heads over and over and over, but what to do *right now* with an unresponsive patient, a very hypotensive patient, etc? And what distressing symptoms constitute a immediate crisis versus an MD call versus a concern to follow up on? Those felt more like tag-ons... oh, well, if the patient is in crisis, assess ABCs and call for help... now did you ensure that the diet ordered was appropriate?

What can I say? The objectives of my nursing program seemed rather vague... it wasn't to be a ready-to-hit-the-floor acute care nurse... those specifics you would learn in the extensive orientation hospitals would provide new grads. To "think like a nurse?" what kind of nurse? public health? acute care? OR? vaccination clinic? It felt like the only clear goal was to pass the NCLEX, to complete X number clinical hours, to check off the skills list, to cover 1000 pages of this and that subject area.... so I vent sometimes, and hope to see positive changes in trends in nursing education. : )

[jjjoy, LPN]

FYI - a moderator editted the original title of the threat. I just had "Rant: student care plans" - the rest was added by a moderator. I do think care plans have a purpose in nursing and nursing education.

[poliwog]

Thank you! As a new nursing student, I found your post very helpful. Im fwding it to my study group. Its nice to have some perspective from the instructor's point of view. Thanks!