Streamlining care plan writing

CharlieT · Jul 26, 2011

20 pages, my goodness, all of my careplans combined wouldn't make that much text

I save all of my careplans on my hard drive along with anything else I type up. This material is often is recycled into new careplans making the new ones less work. Eventually you end up with enough material that new careplans take very little time.

inthere · Jul 26, 2011

20 pages I think is a bit excessive. Mine are only 1 1/4 pages (the school sets the template)

yesicandothis · Jul 26, 2011

20 pages is excessive! For our care plans our professors said 2-5 pages.

LadyinScrubs, ASN, RN · Jul 26, 2011

There are two types of care plans: short or long.

Some long care plans are similar to a term paper. That is, every s/s must be evaluated and explained in reference to the nursing DX. If you have more than one nursing DX, then you have more to explain. If you have past medical hx, you may need to explain how this reflects on your pt's present condition. You will need to explain the treatments the pt received, define the treatment, and what you expect the effect the tx will have or had on the pt. Many care plans require complete info about the IV and meds the pt is receivig. Some careplans reequire a concept map in addition to the care plan.

Care plans can be complex or easy...depending on the school and how many patients you must work up the night before clinical.

ro2878, ADN, BSN · Jul 27, 2011

1 and 1/4 pages???? I want to go to your school!

inthere · Jul 28, 2011

@ro2878, yah I guess I shouldn't complain to much.....page one only contains: the nursing system, selfcare deficit, the NANDA diagnosis with its definition and defining characteristics. The other page consists of a table with the 5 columns each labeled with one of the phases of the nursing process...simle enough

ro2878, ADN, BSN · Jul 28, 2011

inthere: Lucky you - I'm jealous!

We have to prepare 2 care plans the night before clinical. The plan for our primary Pt has to be totally integrated and includes everything LadyinScrubs posted plus additional info (15-20 pages). Our care plan for the secondary Pt is much more abbreviated and is a measly 3-5 pages!

All of this work makes for a very long night, which I believe is a waste of time. I understand the value of being prepared but once you can continually show that you can put together at least a good, or exceptional plan, you should be excused from having to prepare the more lengthy type plans. Time could be much better spent studying or at least getting to bed at a reasonable hour. We always joke about how awful we all look on clinical morning from having to stay up so late! Oh well, what are you going to do - can't change the system.

Best of luck to you in your schooling:)

ro2878, ADN, BSN · Jul 28, 2011

I've been going over some of the many care plan threads and have found a lot of great information about how to do one. However, I am wondering if anyone has any tips for streamlining the writing process. The sound of 20+ page single-spaced care plans is giving me quite a bit of anxiety--especially since writing takes a little longer for me.
Any helpful suggestions to make the care plan writing process go along a little bit faster?

Don't get too worked up. If others can do it, so can you!

I'm sure you've already been advised to get a care plan text book if your school doesn't require one. That helps. Your instructors will give you a blank template and you go from there. It will help you tremendously if you can see a good example of a completed care plan. Ask your instructor for one.

Also, as a previous poster stated, obviously save everything. You will be able to cut and paste the common meds and pathos. After a while you start to get the hang of it and it does start to go faster. However, some times there is just no way to speed it up if you are required to do the longer type care plans. You just know you are in for a long night and you make the best of it.

Good luck!

SNSWTR · Jul 31, 2011

Thanks to everyone who replied to this thread. It was interesting to see the variation in length of care plans required by different schools. If one hates care plan writing, looks like inthere's school is the way to go.

Regarding time saving tips for care plan writing, the message I got is that I should save my care plans and recycle them. I also noticed that NANDA dx was mentioned. Has anyone found that the NANDA reference guide comes in handy?

ro2878, ADN, BSN · Jul 31, 2011

Are you referring to a specific NANDA reference guide published by NANDA? NANDA has its own website with lots of publications which may be useful. My school gave us a laminated card from NANDA with all of the dx listed, but you can find all of the NANDAs in the back of most nursing textbooks. (You will eventually know most of these dx and won't need a reference card.) Each chapter of nursing textbooks will also have sample careplans. Also, most textbooks are written by medical dx, pathology, nursing dx, intervention, labs, and meds. (Sort of like a care plan)

There are lots of care plan writing books. My school recommended Nursing Diagnosis Handbook by Betty Ackley, which I often use and think is worthwhile to purchase. The first quarter of the book lists medical dx with related nursing dx. You then pick a nursing dx that applies to your Pt. Next, you look up the nursing dx in the book and it will list lots of interventions and rationales for your care plan. The back of the book lists nursing dx by Maslow priority, which will help you if your school requires you to prioritize your dx.

You can also use Lippincott's Manual of Nursing Practice, which also lists nursing dx and interventions. I will also pull stuff from here when I am using it for the pathos part of my care plan.

Of course, you can always find samples of care plans online.

Have fun!

theantichick · Aug 1, 2011

My school's care plan is about 5-10 pages of forms that they set out. I'm a computer geek, so I duplicate the formats of the tables & such and type up all my care plans.

Sections:

1) General info - S&S, vitals, CC, Maslow/Erickson, procedures, medical Dx.

2) Lab values, normal ranges & implications

3) Medications w/ primary effect, side effects, required labs, etc.

4) At least two NANDA with S&S, goals, outcome assessment, intervention & rationale.

I've found that I can copy/paste a lot of the lab stuff - the normal ranges & implications; as well as a lot of the medication stuff (everyone seems to be on the same Rx); and some of the NANDA's are pretty similar each time like Risk for Infection and I can re-use some of that.

I'd certainly take a lot longer if I had to write it out long-hand. :) Some hospitals have been okay with me bringing in my netbook, so I can even type all the pt specific stuff straight into my form instead of jotting it down and then trying to read my handwriting later. :)