Do Registered nurses really make a Nursing Care plan for their patients?

meownsmile, BSN, RN · Feb 28, 2007

Yes every patient admitted to a hospital has a nursing care plan. We dont necissarily have to sit and write out the long detailed plan. Most are generated by the computer after we put in their nursing diagnosis. Dont discount having to write those long care plans for school though. They are an invaluable learning tool.

weirdRN, RN · Feb 28, 2007

Yes, some are short some are long but every patient has one.

BGgirl · Feb 28, 2007

Yes we have prefilled ones where you can check boxes that relate to your pts diagnosis and then can add your own info to.

We use comfort careplans a lot, cardiac output, fvd, ineffective airway etc.

It's part of our admission that a careplan has to be initiated for every patient. Some even get more than one.

luckylucyrn · Feb 28, 2007

Plus you are using knowledge you learned in writing care plans during school constantly. You may not think in "Nanda Format" but you think, Hey this person is not oxygenating well, I need to do x interventions to improve that. You use care plans in your head constantly :)

Imafloat, BSN, RN · Feb 28, 2007

We have priorities for care. They aren't care plans per se but are things like "prevent accidental intubation" "prevent infection R/T PICC, PIV, ETT." We don't have to write the interventions and objective out but we do heed the priorities.

I thought all the careplans, APA papers, all the hoops that I jumped through during nursing school were just hoops. Now that I am 4 months in I am starting to see how those things molded the way I think about things at work. There is a method to the madness, it is just difficult to see when you are in the midst of it.

NoMoreStudying · Feb 28, 2007

It's usually generated by the dx or chief complaint. So I get several boxes to fill in on the computer and it may also prompt things like a neuro, neurovascular, etc assessment, or treatments like elevate HOB.

But yes, it's all about teaching you how to think. Most of it is in your head. As tedious as they are, it's worth it. Say you get an abd pain with n/v. Well, you need to remember to assess not just pain and nausea, but bowel sounds and habits, po tolerance, output, hydration status, etc. Taking that extra step. Then maybe even farther. Are they an SBO that's on the verge of septic shock and now we need to be even more diligent, where as pain and nausea are a little lower on the priority list.

And the biggest part it teaches you? what are you doing (meds and beyond) and is it helping? B/c you can document all day long but if you aren't showing how they respond to treatment, good and bad, we might as well go home.

I always think of it as where they are in the progression of their disease, and what is one step worse or better. Then I have my framework to work with. If it's an elderly person with a UTI, is their mental status clearing, is their urine output adequate and what does it look like, is their BP holding. Right there I can give a pretty good picture and someone can tell how they are progressing. Then I can go into decubs, etc if I need.

As much as I hated writing them, you'll be able to tell which people didn't pay any attention to them when you get out and start practicing. They don't show the whole picture.

TrudyRN · Feb 28, 2007

We do one for q pt upon admission and update it PRN.

styRN · Feb 28, 2007

Yep.

LTC facilities are mandated in my province to initiate a NCP within 24hrs of admission and have one completed within 7 days. This plan must include 8 facets of ADLs, continence care levels, actual and potential risks for injury from falls, skin breakdown, heat related illness, and must also include goals/outcomes for pain control, ineffective coping, as well as needs R/T each diagnosis (usually primary and 1 secondary) in addition to a nutritional plan and mobility plan. All of these items must appear on each and every care plan, and once completed, they are reviewed/changed a minimum of q3 months or prn.

Doesn't sound like alot of work, but each one takes approx 60 minutes to complete and when you have 320 patients and only a very small number of RNs doing the documentation, it can be overwhelming.

Unfortunately, all of this work is done more for government funding of our facilities, as the ministry of health utilizes them to classify our patients according to their physical needs requirements and distributes funds accordingly.

My wife, however, works on surgery and they follow pre-established, generic 'care paths' that have been developed, which cover the basics. Just fill-in-the-blanks, so to speak.

I agree with others in that even if you don't literally use NCPs in your practice, the knowledge of the nursing process garnered from doing them in clinical settings as a student is essential to nursing anywhere. Don't think so much of a NCP as something you complete once and stick it in a chart or kardex; think of it is the way you should be thinking through any actual or potential problem or need your client may have.

TazziRN, RN · Feb 28, 2007

I have not written one or even seen one since I finished school, because I work ER, but I think in care plan mode with each pt. Learning how to write out care plans teaches you to think and anticipate potential problems.

Hoozdo, ADN · Feb 28, 2007

They aren't care plans per se but are things like "prevent accidental intubation" .

1. Do not allow pulmnologist in pt's room

2. Do not permit respiratory therapist to look at pt

3. Never put pulse ox on pt!

4. Above all, do not ever listen to lungs!

:roll:chuckle

Sorry, just joking.

TazziRN, RN · Feb 28, 2007

1. Do not allow pulmnologist in pt's room
2. Do not permit respiratory therapist to look at pt
3. Never put pulse ox on pt!
4. Above all, do not ever listen to lungs!
:roll:chuckle
Sorry, just joking.

I liked #1!!