Careplans in your head?

[Troischats]

Hello all,

First off, I'm in nursing school, so not officially an RN, but if you'll allow me to stick around for just a sec to ask a question... I'm very curious as to how you go about care planning once an RN. When we first started school, and care planning, I thought if nurses are soooo busy how on earth do they have time to sit down and do all this? That's when an instructor said, you don't, you do it in your head, multiple times each day. I guess I'm wondering if there is documentation you have to do as well in regards to care planning? What's the procedure? I simply don't know!

Best wishes and thanks much for your time!

[Katnip, RN]

Depends on the facility and unit.

But I've never seen a nurse have to write a care plan. That would be ridiculous.

I worked in one unit that had pre-made care plans/protocols for certain diseases and surgeries. We put them in the daily chart.

[bargainhound, RN]

Facilities have different ways of documenting this.

Some are computerized. Some are on paper.

Sometimes there is one person whose job it is to do this, such

as in nursing homes.

Procedures vary according to documentation process at the facility.

That is, it may be based on different software programs.

So, basically it is similar info, just in differnent formats.

You may even enter it on a handheld device as you do assessments

at some hospitals.

Change is everywhere and always ongoing, just expect it and be ready

to learn always as you continue your career.

Just get basic concepts down, then it will come automatically as to

what you do for what type patient/presenting problem.

It also helps to think of similar type patient that you cared for

previously and what helped that person.

[bargainhound, RN]

I have to disagree about the care plans.

They are time consuming, but they are still around.

[SCRN1]

On admission, the computer already has it figured out for you, depending on what diagnosis you put in and you can say yes to apply it. You can also apply more as needed. They are supposed to be updated daily if there have been any changes.

[wooh, BSN, RN]

Depending on where you work, there's different "care plan" processes. But the important thing is, the ones you do in nursing school teach you to think through the process. In real life I don't write a care plan. But I can automatically think through it. The nursing school care plans teach you to do this. To think about not just how to do a task (which seems to be every student and new nurse's biggest worry), but WHY you're doing it, and to make sure you go back and see if it worked.

[dijaqrn]

Care planning in your head is quite an appropriate statement. I have been around since we wrote care plans by hand, now the computer does it for you but you( the nurse) have to select your problems, choose appropriate goals and interventions and evaluate them. You don't sit at the computer to do this, it's ongoing "in your head" throughout your shift. When you finally get a moment to chart you'll modify care plans, discontinue goals and interventions that have been met and formulate new ones. You may also identify new problems to plan for etc.Good luck!!!!!!!!!!

[AfloydRN, BSN, RN]

When we do an admission assessment, we choose care plans that are appropriate on the computer. It's pretty simple. If the patient has COPD, the ineffective airway clearance prompt pops up and you select it. We too spent sooo much time on them in school.

[Daytonite, BSN, RN]

Troischats. . .If you hang out at all on the Nursing Student Assitance Forum or the General Nursing Student Discussion Forum you will find care plan threads where I address care plans and the nursing process all the time. A care plan is nothing more than the written expression of the nursing process. The nursing process itself encompasses the activity of critical thinking. Critical thinking is very simply making judgments based on facts rather than making random guesses based on nothing. You need to use sound principles of nursing and the nursing process as a nurse. As a student you are learning to do this. As a mature, licensed and experienced professional you will be able to do it without a thought as to what you are engaging your brain in doing. The steps of the nursing process, knowledge of diseases and their treatment as well as knowledge of the principles of nursing practice and appropriate interventions are all involved in making these daily decisions which can be committed to paper (or electronically, nowadays) in the form of a "care plan". When you hear educators and nursing leaders talk about critical thinking you can infer that the nursing process and care planning is most definitely involved. This business of critical thinking and the nursing process is the one thing you have to master to truly be a professional nurse.

Now, having been a manager, I have to disagree with some of the things said by some of the others who have posted to this thread. Written care plans are required documentation in the charts of Medicare patients. That's in the Medicare federal law. Each hospital goes about handling this requirement differently. Many have found that using a care plan "shell" works best. A "shell" is a pre-written, generic care plan that can be easily and quickly customized and individualized for any specific patient. I know how these work as I was a member of a care plan committee at one hospital that wrote these "shells". We met on a regular basis to review and revise them. While most of the staff reap the reward of just grabbing one of these and running with it, there is acutally one or more nurses who sit down and put work and effort into them. As a manager, it was part of my responsibility to make sure that the staff nurses under my supervision were held accountable for completing care plans as part of their documentation duties. Perhaps my colleagues have forgotten the emphasis that is placed on this when they went through their job orientations and at each of their yearly performance reviews. One of the things I did as a manager was periodically check charts to see what kind of charting the nurses were doing as well as check the care plans to see what kind of care planning was being done. It has been my experience that there is a big difference between not having the time to write a care plan and not writing care plans because one still doesn't understand how to do them. And that, my friends, is a truth.

[Tiwi]

Care plans are important, and I found it initially hard to work out what was required for individual care. Where I am, we still use non computerised recording. Even if you use a standardised care plan, it is important to assess the individual so that his / hers personal concerns are all addressed. With experience, you will find it easier. But remember also, over years, things change, as does care, so care plans will have different content in the future, meaning that we are always learning to write the darn things

[nursemike, ASN, RN]

We use a sheet(actually several pages)that you just check off problems or potential problems, goals, and outcomes. Pretty convenient. Our Clinical

Preceptor told me she lays out her notes on her Kardexes in a manner similar to what my instructors in school called a "concept map". Systems are grouped roughly as they might relate--a stroke pt. will have his neuro data near his musculoskeletal, for example. I tend to put little sections for each system in the same place, every time, because it's easier for me to be methodical that way, but I tend to allocate space by priority. A recent stroke from home probably won't need a lot of notes on integument, but may need more room than some others on GI/GU. But if I see a pt with a trach, I know I'm going to have to assess and intervene for skin integrity, too. Most of this is done before report, and it evolves during report, and evolves more after my initial assessment.

I hated careplans more than anyone else in my class, but probably got more benefit from them, too. In practice, the ones in my head are less formal than the ones in school. But this is evolving, too. Early on, it seemed like all I could do to pass meds and keep up with what's ordered on a full assignment. As I get a bit more comfortable with that, I am more able to plan for potential Nsg Dx, and even to be a little more thorough in my documentation. As one of my mentors puts it, if you do chest PT, give yourself credit by making a note about it.

[Daytonite, BSN, RN]

The one thing that changes about care plan writing over the years is the style in which they are done. When I was in school back in the 70s we were taught to put down a single patient "problem" and interventions for that on the patient's care plan. That has evolved to nursing diagnoses which clusters, or groups, similar problems under one related diagnostic statement. Care maps are doing something similar. Final line: we are still addressing and carrying out interventions for the patients "problems". That is never going to change.