just registered/careplans

[Priti]

hi

this site is awesome very informative. i am a 26 year old female, i live in the caribbean. i have recently qualified as an rn and has also done a post basic course - midwifery currently employed as a clinic nurse.

i have one question

in the country where i work written care plans are not routinely done. most of the students would put it to the nurse managers but its not used because most of the older nurses are set in their ways sometimes a student would start it and on returning to the ward the next day it would be untouched. i have found that its becoming increasingly difficult to remember standard nursing diagnosis because of lack of practice; i myself working as a staff nurse realize that its difficult to make careplans on admission because we are understaff (most times one staff nurse with one junior staff for about 20 patients). i read in my spare time but thats not adequate

the nursing process defines us as nurses and i find it a shame that these nurse managers can't see it to implement the stage that allows for documented continuity of patient care.

Do you have any suggestions?

dedicated to nursing

[oceanblue]

Don't really have any suggestions, but just wandering.....where are you in the Caribbean?

I love the Caribbean!!!!

[Priti]

Don't really have any suggestions, but just wandering.....where are you in the Caribbean?

I love the Caribbean!!!!

i am a resident of antigua.

[NurseDiva04]

i am a resident of antigua.

Welcome to the board. I am not a nurse yet. Will start school next month. I have been to Antigua and would love to build a home there!

[Priti]

Welcome to the board. I am not a nurse yet. Will start school next month. I have been to Antigua and would love to build a home there!

well

welcome to the league its a really great profession and good luck with your dream home.

[chris_at_lucas_RN, RN]

I've been to your island (and can pronounce it properly!!! :) ) and have also been to Montserrat for about a month. Lovely, lovely part of the world.

As to your question about care planning. In the US, it appears to me (with my limited experience but also what other nurses have shared) that care plans are often done automatically by computer.

As a student, I found care planning helpful because it forced me to address each aspect of the nursing process. But nurses on a med surg floor may not have the luxury of actually writing out all the steps.

You might pick up a copy of Carpenito's Nursing Diagnosis: Application to Clinical Practice, since getting the nursing diagnosis right in the first place is important. This book also carries the process a bit further, suggesting possible signs and symptoms, possible interventions, possible coinciding problems.

Here is a link for the googled sources I found: (link) I found this particular book on ebay (two listings) for about $5 plus shipping, which is a nice savings on the list price.

[susanna]

You might pick up a copy of Carpenito's Nursing Diagnosis: Application to Clinical Practice, since getting the nursing diagnosis right in the first place is important. This book also carries the process a bit further, suggesting possible signs and symptoms, possible interventions, possible coinciding problems.

Here is a link for the googled sources I found: (link) I found this particular book on ebay (two listings) for about $5 plus shipping, which is a nice savings on the list price.

How are nursing diagnoses and care plans interwoven? Are they the same thing? This is coming from a non-nurse.

[Priti]

I've been to your island (and can pronounce it properly!!! :) ) and have also been to Montserrat for about a month. Lovely, lovely part of the world.

As to your question about care planning. In the US, it appears to me (with my limited experience but also what other nurses have shared) that care plans are often done automatically by computer.

As a student, I found care planning helpful because it forced me to address each aspect of the nursing process. But nurses on a med surg floor may not have the luxury of actually writing out all the steps.

You might pick up a copy of Carpenito's Nursing Diagnosis: Application to Clinical Practice, since getting the nursing diagnosis right in the first place is important. This book also carries the process a bit further, suggesting possible signs and symptoms, possible interventions, possible coinciding problems.

Here is a link for the googled sources I found: (link) I found this particular book on ebay (two listings) for about $5 plus shipping, which is a nice savings on the list price.

thanks for the suggestion but i do have a copy of that book. what i am saying is that we use the nursing process in our day to day work as nurses but the step of writing the care plans we just do not practice, it was taught at school but it remained there as new grads you would want to continue using it but the majority doesn't and after some time the enthusiasm just deteriorate.

monserrat is in fact beautiful but have you ever visited dominica comonly referred to as the nature isle. well i am now and i am having a blast bathing in rivers, going to rain forest the air is just so pure and clean.

[chris_at_lucas_RN, RN]

How are nursing diagnoses and care plans interwoven? Are they the same thing? This is coming from a non-nurse.

There are basically two kinds of nursing diagnoses: actual and potential. The actual ones, the patient already has. The potential ones, s/he might get.

A nursing diagnosis has three parts (two for potential, and you will see why). First part is the patient's actual problem. We'll pick something easy (for us, not the patient), "acute pain."

The second part is what the problem is "related to" (sometimes abbreviated "r/t"). Say our patient has broken his/her leg. So, so far we have, Acute pain related to fractured femur....

Because this is an "actual" diagnosis, we also have signs and symptoms (sometimes abbreviated "S/S"), which we describe as "as evidenced by" (you guessed it, sometimes abbreviated "AEB"). In this case, our patient is moaning and grimacing, and rating his pain 8 on a scale of 1 to 10 (where 1 is nothing or near nothing, and 10 is the worst the patient can imagine).

So now we have "acute pain related to fractured femur as evidenced by grimacing, moaning and patient report of pain at 8 on a scale of 1 to 10."

That's the nursing diagnosis.

The care plan would include the diagnosis, but it would also include interventions to relieve the problem(s), in this case, acute pain. We might administer pain meds as prescribed, reposition the patient, provide support in the form of distraction or skills to help them relax and focus, we might apply cold or warmth to the site.

Before doing the interventions (we are still in the "planning" phase, after all), we would identify a goal for each of the interventions that would let us know if the intervention had been helpful. We might say that the patient's goal (and it is always the patient's goal, not the nurse's) is to report pain at no more than 4 on a scale of 1-10 within one hour of administering the medication, for example.

And then we would go assess the patient (don't want to do an intervention and they don't need it--assessment lets us know they still need it) and do our interventions, and then we would assess whether the intervention worked. And the whole thing gets charted. And when the "problem" is resolved, then that diagnosis is not accurate anymore, so we adjust it.

And that's how, in a very simplistic way (and maybe not accurate--so if I'm wrong somebody come in here and fix this so people aren't left with the wrong impression!), the nursing diagnosis interweaves with care planning and actual nursing care.

Terrific question.

[chris_at_lucas_RN, RN]

we use the nursing process in our day to day work as nurses but the step of writing the care plans we just do not practice, it was taught at school but it remained there as new grads you would want to continue using it but the majority doesn't and after some time the enthusiasm just deteriorate.

It's the same here. I am the only one I know of (nurses and nursing students alike) who enjoyed care planning. I was fascinated by it and really like how it make the process so much tighter.

But there isn't time for that if you have 6-8 (or more) post surgical patients. And the computer is so much more accurate. At least that's what I've been told....

I would almost suspect that if it weren't required by JCAHO or somebody, hospitals wouldn't have care plans at all--labor expensive and not seen to increase productivity all that much....

[Priti]

There are basically two kinds of nursing diagnoses: actual and potential. The actual ones, the patient already has. The potential ones, s/he might get.

A nursing diagnosis has three parts (two for potential, and you will see why). First part is the patient's actual problem. We'll pick something easy (for us, not the patient), "acute pain."

The second part is what the problem is "related to" (sometimes abbreviated "r/t"). Say our patient has broken his/her leg. So, so far we have, Acute pain related to fractured femur....

Because this is an "actual" diagnosis, we also have signs and symptoms (sometimes abbreviated "S/S"), which we describe as "as evidenced by" (you guessed it, sometimes abbreviated "AEB"). In this case, our patient is moaning and grimacing, and rating his pain 8 on a scale of 1 to 10 (where 1 is nothing or near nothing, and 10 is the worst the patient can imagine).

So now we have "acute pain related to fractured femur as evidenced by grimacing, moaning and patient report of pain at 8 on a scale of 1 to 10."

That's the nursing diagnosis.

The care plan would include the diagnosis, but it would also include interventions to relieve the problem(s), in this case, acute pain. We might administer pain meds as prescribed, reposition the patient, provide support in the form of distraction or skills to help them relax and focus, we might apply cold or warmth to the site.

Before doing the interventions (we are still in the "planning" phase, after all), we would identify a goal for each of the interventions that would let us know if the intervention had been helpful. We might say that the patient's goal (and it is always the patient's goal, not the nurse's) is to report pain at no more than 4 on a scale of 1-10 within one hour of administering the medication, for example.

And then we would go assess the patient (don't want to do an intervention and they don't need it--assessment lets us know they still need it) and do our interventions, and then we would assess whether the intervention worked. And the whole thing gets charted. And when the "problem" is resolved, then that diagnosis is not accurate anymore, so we adjust it.

And that's how, in a very simplistic way (and maybe not accurate--so if I'm wrong somebody come in here and fix this so people aren't left with the wrong impression!), the nursing diagnosis interweaves with care planning and actual nursing care.

Terrific question.

terrific reply couldn't make it simpler:kiss

[purplemania, BSN, RN]

Our facility has pre-printed forms that follow Joint Commission guidelines. There are blank spaces for the nurse to add information that is not already provided on the form. Students in Texas are not allowed to create a careplan, only a licensed nurse may do so. The student may followup on the teaching, but the nurse must create the plan of care. Care plans MUST be done upon admission (within 8 hours at our facility). A nurse must document that the care plan is reviewed every 24 hours and document any changes, including to whom the education was directed (patient, family,etc.).

Before we had the pre-printed forms I laminated a copy of the NANDA nursing diagnoses and kept it at the nurse's station. Hope this helps.