? for nursing DX

deeDawntee, RN · Sep 18, 2007

Yes, it will still show up on your job. You will still have care plans for each of your patients based on Medical diagnosis. They are set up with nursing diagnosis for each body system plus pain, emotional, education etc and we address the care plan each shift. Our documentation is normally based on charting by exception (charting the abnormals). We have just converted over to computer charting, so we chose a care plan based on the main diagnosis (I work in ICU so we have a Critical Care-Care Plan) and then secondary issues can be added, such as diabetes, or ETOH withdrawal etc.

So yes, dear one, care plans will be there, but they are already formulated for you. You just choose them and depending on where you work, acknowledge their existence in some way. (JCAHO standards)

Hang in there. This too shall pass! ;)

Achoo!, LPN · Sep 18, 2007

In my area, we do not do care plans at doctors offices. You only document vitals, hx, cheif complaint, treatments, etc. The MD dictates the rest. You will do alot of teaching as well. We still do paper charting though, so I am not sure about computerized charting in doc offices.

Daytonite, BSN, RN · Sep 19, 2007

Jessica. . .the nursing process IS what professional nursing is all about. It is how you ultimately make all decisions regarding patient care that you give. School is just showing you how the process is broken down and written out on paper. On the job you "think" through this process so rapidly after time that you don't even know you are doing it.

The nursing process is an extrapolation of the scientific process. It is rational thinking. We use it in our everyday lives. Let me explain. When you discover something is broken you investigate the problem to try to determine what is wrong and then try to fix it. If what you do to fix it works, great! If it doesn't then you try something else. That is the nursing process in a nutshell.

Assessment

- investigate a broken something or other

Determine the problem

- determine what is wrong based on your investigation

Plan care

- figure out some thing(s) [interventions] to fix the problem

Put the plan into action

- apply your interventions

Evaluation

- did they work? if not, you go through the process again until you get to a satisfactory conclusion or give up

Now, you can't tell me that you haven't done this before in your life. Nursing school is merely giving it a name and requiring you to use it in the nursing care of patients. There is rationale behind the choosing of nursing diagnoses (patient problems) and it starts with a thorough assessment of the patient and determining what isn't normal about the assessment. Nursing school says you need to take this very same process and do this:

Assessment

- collect data by doing a physical assessment of the patient and review their medical record

Determine the problem

- separate out the abnormal data and determine the patient's problems, naming them as nursing diagnoses

Plan care

- determine goals and interventions for the abnormal data

Put the plan into action

- apply your interventions

Evaluation

- did you achieve the goals? if not, you amend your plan of care and try different interventions

So, when you ask, "will nurses have to use nursing process in any floors or any nursing area such as ER, L&D, doctor offices, OR, etc?" the answer is "yes". However, you use this same process every single day of your life to solve problems. Professional nurses are problem solvers. This is the one great skill that nursing school is teaching you above all others. You are expected to use information from the sciences, medical treatment, knowledge of drugs and nursing theory to help you in this problem solving process. I am afraid that you are not going to find any career where you do not have to solve problems and that includes flipping burgers at McDonalds.

My suggestion is to take a little break and relax. When you are more rested and relaxed read the first pages of a care plan or nursing diagnosis book where they discuss the nursing process. It is only a few pages long. Take your time reading it. Think about each sentence and each paragraph. Take another break. Read it again at another time. And again. Eventually it will begin to make sense to you. Think of it as a familiar process cloaked in a disguise that you are just not seeing clearly at the moment. In time, you will "get it". Also, like the analogy I gave you above, think about all the times you solve problems in your own life. It is not any different. The process is still the same. Nursing school just gives it fancy labels and the instructors want you to write it all out on a piece of paper to help you break the process apart and understand every single little step of it and what goes into those steps. That's what college is all about--analysis of these things.

Hope that helps you put it into a different perspective. It's not worth quitting school over. You're only going to run into the same process again throughout your life: different names attached to it, different information being processed, bottom line always the same--solving the problem. Also, this is a complex concept. Do not expect to have a total understanding of it in one reading. Give yourself time to digest it. When I was in my BSN program we had a whole 10 week course that covered this and we were still confused about it. I really didn't have a good understanding of it until well after I had graduated.