Nursing Care Plans

[SkinnyLatte]

Hello everyone!

I am currently enrolled in a CNA course and will be applying to the RN program very soon. In my CNA class, patient care plans are pushed big time. Everything we go over (ROM, BRP ect) is said to be somewhere in the patien's care plan. In quite a few threads I've read on here, I've noticed that it's been said that most of the time nurses dont even have time to even look at the care plans let alone follow them. Is this true? How does one go about assessing the patient's needs if the care plan isnt utilized?

Thanks again!

Ashleigh

[klone, MSN, RN]

Hello everyone!

How does one go about assessing the patient's needs if the care plan isnt utilized?

Thanks again!

Ashleigh

By using your critical thinking skills. You know why the patient is there, you know his/her diagnosis, and you know what typical needs a patient would have with that diagnosis. The rest, you're generally able to figure out by observing the patient, assessing the pt, talking to the pt, etc.

[OttawaRPN]

Use the Kardex, the chart, the patient's expectations and your own assessment skills to determine the plan of care.

The traditional care plans have gone the way of the dinosaurs... extinct.

[SkinnyLatte]

Thanks so much for your input. I was just wondering how much emphasis is put on the care plan b/c it's definitely pounded into our head in class. Care plan. care plan. care plan. And my teacher is an RN but it just kind of makes me wonder how much she's actually used one in her career or if she's pushing it b/c the curriculum requires it.

[klone, MSN, RN]

The traditional care plans have gone the way of the dinosaurs... extinct.

I wish. I think JCAHO still has an expectation of them.

[ImThatGuy, BSN, RN]

Why do you need a care plan at all to make an assessment, diagnose, and intervene? You don't.

[fsaav]

It depends on the facility where you work. At my hospital we use computerized charting and the expectation is that each shift will complete care plans. This includes a problem list and whether the pt has met this goal and it is no longer applicable, whether it was met this shift, whther they are progressing, or whether the pt has not met this goal. If they have not met the goal we fill out a variance for that problem and state the problem, interventions, pt's response, and follow-up actions. It sounds tedious, but really it only takes a few minutes and I like them because they really makes you think about some things that you otherwise might not have time to stop and thing about, i.e. what ARE we doing about the patient's elevated BUN and creatinine?

[sunnycalifRN]

Thanks so much for your input. I was just wondering how much emphasis is put on the care plan b/c it's definitely pounded into our head in class. Care plan. care plan. care plan. And my teacher is an RN but it just kind of makes me wonder how much she's actually used one in her career or if she's pushing it b/c the curriculum requires it.

You got it! The care plans that we're all taught in nursing school are definitely not used. I'm sure that all nurses have a general plan of care for each patient, in their head, but you don't have time to write one out, with multiple nursing diagnoses (puke!!). Maybe there's a nursing instructor on Allnurses who uses a written care plan . . . but most bedside nurses don't have time.

[tewdles, RN]

Just like other disciplines must document their professional assessments and plans to correct or improve any issues, so also must nursing.

Many acute care nurses work from a medical rather than nursing POC, but there is a nursing POC in the chart...or at least should be.

[Hospice Nurse LPN, BSN, RN]

Our plans of care are a check off. It's updated with each recertification period and PRN.

[Elvish, BSN, DNP, RN, NP]

Part of the point of care plans in nursing school (and I don't know a soul who liked them!) is to get you thinking about what the patient needs, based on his medical diagnoses, your physical assessment, and whatever treatments have been ordered. You list these needs, you list interventions you can perform to meet those needs, and you evaluate whether they worked or not.

For nursing school, the care plan is usually a one-time thing, set to help you think about your patient(s) for clinical and how you will best take care of them for those several hours. In nursing-world, you do the same thing...only most of it takes place in your head, and it takes place many many times over in the course of a shift, and most of it never gets written down.

On my floor, there is a preprinted plan of care. Nursing diagnoses, interventions, and desired outcomes are preprinted, and we check them off as applicable. It has to be opened on admit and the problems closed as appropriate. Once the problem no longer applies, there is a space for us to sign and date indicating we've 'closed' that problem. There are also blank spaces for us to use in case none of the preprinted stuff applies to a particular problem. I work nights and when I do chart audits, I take a look at the careplan to see if anything needs to be closed or opened. Other than that...I will be honest, I don't think anyone actually looks at them. But they are a requirement.

[tewdles, RN]

The hospice I work for requires that we create a nursing plan of care, using NANDA type language, and document patient progress toward goals regularly. Our POCs are electronic and we can customize the problems, interventions, and goals as needed...or we can simply choose from a comprehensive listing.

All professional health care disciplines document a plan for their care of the patient. In many instances it is a requirement for reimbursement...and in instances where it currently is not, it may be required soon enough.