Careplan at work

[Cat_RN, ASN, BSN, RN]

Are you guys expected to update careplans at your job with changes in condition/situation?

Curious because we are, and I kind of always thought this was a managerial or administrative thing.

[xtxrn, ASN, RN]

Absolutely when I worked the floor, and as charge- it was expected to review them all every shift. :) (that was hospital)

When I worked LTC, I ended up doing the care plans for the Medicare patients, and all change of conditions and new admissions; the other MDS nurse took the non-skilled quarterlies and annuals w/no changes in conditions (1/4's or yearly). The floor nurses in LTC were SUPPOSED to check the care plans, and let me know if there were new orders that needed CP attention.

[Always_Learning, BSN, RN]

Yes indeed.

[elthia]

Yes every shift, every admit, every transfer, and as changes in condition warrant.

[maelstrom143]

Yes. At our facility we have to review the care plans and update them as needed at least once a shift and with any changes that affect the POC.

[loriangel14, RN]

Yes where I work we are responsible for updating our patient's care plan every time there is a change.Sometimes it's the unit clerk that will update them, sometimes the charge, sometimes it's us.

[classicdame, MSN, EdD]

I think the poster was referring to the creation of careplan templates. As others have mentioned, it is the job of the primary nurse to determine the plan for that patient. Our new e-medical records system designs the plan for us, based on assessment. Still, it has to be revised q 24 hours minimally.

[merlee]

It's a NURSING plan of care. Nurses are supposed to do it.

[vashtee, RN]

We have to do them once every 24 hours, so nights are responsible Tu/Th/Sat/Sun, and day shift does M/W/F. I work days, and they are an extraordinary waste of time I don't have, IMO.

Yay, NANDA. I appreciate nurses who don't think we have enough to do as it is...

[EmergencyNrse]

Care plans @ work???

[Dixielee, BSN, RN]

Care plans @ work???

That's what I was thinking, I thought care plans ended when you graduated. I am so thankful I don't have to deal with them anymore...am very thankful for ER!!

Our care plan usually involves:

1) Keep the patient breathing

2) Stop or slow the bleeding as much as possible

3) Give enough short acting meds to get their BP below stroke level or stop the MI or stroke from evolving, alleviate the pain.

4) Send home, cath lab, surgery, ICU, or floor as soon as humanly possible

5) Clean stretcher quickly, put new patient in it...then, see # 1, repeat until shift ends. Report to next nurse who will continue same

[turnforthenurse, MSN, NP]

We were expected to review/revise at least once/shift.

However, now our system is changing - now we are implementing IPOC, or interdisciplinary plans of care. They include nursing care plans (and a lot more in-depth than what we had originally - with interventions and goals/outcomes!) but being interdisciplinary, means that all disciplines can document on the same IPOC form (RT, PT/OT, nutrition, etc). Some of the goals relate to vital signs (for example, "will maintain O2 sats of 90% or greater") and every time O2 sats are charted as part of the vital signs in our charting system, it will automatically populate in the IPOC and will show up with green check marks (patient is meeting the goal) or red x's (patient is not meeting the goal). Then we can go back and add comments/interventions, etc. So in a way, yes, now we are expected to review/revise with patient changes.