What is it about Care Planning that you find most challenging?

203bravo, MSN, APRN · Apr 27, 2014

All of our care plans require 3 nursing Dx and we do them based on actual pts from our clinical rotations. The thing that I find most challenging about them is the time commitment it takes to do them -- can actually write them from the NANDA guide book and get the nursing interventions (with the rationals) that we preformed during that rotation.

In my mind, the care plan would serve us better if it was thought about and written prior to our clinical not after the fact - what nursing interventions would be plan on doing for this pt rather than what interventions we did during the shift and write it after the shift is done.

Also, our instructors want us to include an outcome goal for the shift as well as a pt behavioral goal for the shift and they cannot reference the same goals -- sometimes these are just going to be the same and there is nothing you can really do to make them different.

Hope this helps you a little.. :)

Thanks for taking the time to ask such a question to attempt to help your students better understand.. wish more instructors would act in such in such a manner.

vintagemother, BSN, CNA, LVN, RN · Apr 27, 2014

Care plans....

Each instructor taught us different ways to do them. Some wanted verbatim quotes from the care plan book. (Lippincott?) some wanted us to write them while mentioning our residents specific problems.

Some clinical teachers wanted 1-3 each day! Some wanted one each week.

After I really understood care plans, I enjoyed them because they helped me to understand nursing interventions better as well as helped me to understand the medical diagnosis and how it related to the nursing diagnosis. I loved digging into the pathophysiology of a disease so that I could learn enough to write a good care plan. Eventually, I learned to whip them together very quickly.

I used 1-2 care plan books plus my med book to complete them.

At first they took me hours to do and I had to be in a silent environment. Later on, they took less than 30 mins.

I really appreciated when the instructor would sit down with me privately to discuss my patient and how I could write a better care plan.

I *hated* when they marked them up with a red pen and all sorts of illegible and non sensical scribbles.

smf0903 · Apr 28, 2014

What was your last Care Plan about? (Case study? Actual patient?)

**The last care plan I did was on an actual patient (all of ours are on actual patients, at least for clinicals). The most recent was a cardiac care plan and was on a patient who was fitted our first day of clinical for an external defibrillator.

What were the learning objectives for that assignment? (IOW: What was your instructor looking for?)

**For our care plans in the clinical setting, we have a specific assessment we are to do, and then we're to write a care plan based on that particular assessment. I think our instructor looks specifically for measurable, realistic goals for both day-of-care and for discharge. I think she also wants to ensure we are picking out the top priority for that patient's set of circumstances.

About how much time and how many books/references did you use to complete it?

**I usually use 2-3 sources and have gotten pretty good at putting a care plan together in about 30 or so minutes.

How many do your write in a semester?

**Usually around 5-6 a semester.

What major sections make up your care plan forms. AND, finally...

**Nursing dx, interventions with rationales, day-of-care goals, discharge goals, whether or not goal was met and if not a revision to the plan, and references.

What did you find most challenging (difficult or confusing) about the assignment?

**The most difficult thing I find with some care plans is what is priority. I tend to, when in doubt, fall back on Maslow. However, some times I really still find it difficult to pick out that one top issue. An example of this was from this semester; I had a patient who was in with a dx of syncope. She was going to be put on Coumadin post-discharge (a new med for her). If I recall correctly, she had a permanent pace put in during her hospitalization, which was to take care of the syncope (again, if I remember right, she was having 8-10 second pauses). Anyhoo, while talking with her I found out she was worried about not being able to afford the Coumadin and had no idea what precautions/foods/etc would change with the new med (which turned out to be a great teaching opportunity). So, while a majority of the data I collected had to do with what led up to her hospitalization and her syncope, I felt the bigger problem for her NOW was med compliance r/t her small monthly income and a new medication she had not anticipated. So that's what I struggle with sometimes.

I think it's great you are seeking out information to help your students! I was really freaked out about care plans when we first started doing them, but I rather enjoy doing them now. :)

la_chica_suerte85, BSN, RN · Apr 28, 2014

I think the biggest issue for me so far with care plans is that I have had to focus so much on getting pt info in the relatively small amount of time available in my past clinicals. It was difficult to do that and spend any time with the pt while acting as CNA or going to different procedures that care plans became very difficult to conceptualize. When I see "nursing interventions" on my lecture slides, it still doesn't sink in (I'm freaking dense, in reality) and I was struggling somewhat with actually devising what I could do for my assigned pts. Now, however, I have a 12-hour day where I see my pt from morning to evening and can see how he or she either improves or declines and I actually get to adjust my nursing interventions from there. It is finally starting to crystallize in my mind how this actually works instead of just "playing pretend" with interventions that I never even actually got to try. There was also a significant feeling of being an impostor that went along with this.

I'm just getting done with fundamentals this quarter so I'm not sure what level you're teaching at but I think that, until students really get to start actually functioning in the clinical setting as a nurse, it remains difficult to really internalize interventions. With this, it becomes difficult to prioritize diagnoses (not to mention making them in the first place), especially when you're trying to devise how the plan logically should go according to the pt's medical diagnosis and not how it really ends up working. My experience in my first 12-hour day, while difficult, gave me a very clear picture of what intensive pt care is about and how assessment is so important and how incredibly helpful those assessments are in making a real plan of care.

Finally, our instructor has given us a gift. She is allowing us to revise our practice care plan as our care plan #1 (we have 3 SBAR/Care Plan/Clinical Reflections due and the 1st set is practice with the following 2 comprising the majority of our points for the clinical). This takes a tremendous amount of pressure off and lets me actually see if my "nurse logic" is developing at all and gives me a shot at redemption. I think, if any other program is similar to mine and care plans comprise the majority of the grade, this is an incredibly merciful way to do things (especially since I'm a little more concerned about mastering the h-to-t assessment that we are also expected to perform this quarter). This lets me focus on my pts for the next month or so without having to worry about gathering new data for an entirely new care plan and I can work more on my assessments and doing real interventions (the RNs on my unit are more than happy to let us do anything and everything -- even if we're not technically qualified to do it so there's definitely no shortage of opportunity at bagging skills this quarter).

Btw, let it be known that I don't hate care plans. I actually dig the research and pathophysiology and med cards and all that. Yes, it takes a very long time to do one but I live for the research aspect -- big nerd alert! It just gets frustrating when I feel like I'm pretending the whole way.

Esme12, ASN, BSN, RN · Apr 28, 2014

The hardest part of the care plan in reality is the assessment. Getting a way to maximize assessment in a short period of time. Nurses do this everyday with multiple patients. It takes time to learn how to focus your assessment and get the "right" important information.

I have in my sig line a worksheet to help you focus that assessment.

Cuddleswithpuddles · Apr 28, 2014

My last care plans were at least three years ago and long forgotten.

I do remember the most difficult thing about them, though: Figuring out the individual professor's expectations. No matter how supposedly codified nursing diagnoses and interventions are, every professor still has their own quirks in format, verbiage, prioritization etc.

In my experience, writing care plans was more about pleasing the prof. An authentic demonstration of assessment and prioritization skills and background knowledge of pathophysiology were secondary.

Eh, that's school life for ya sometimes.

As for "real-life" care planning, I agree with esme12. The most difficult is the assessment part.

203bravo, MSN, APRN · Apr 28, 2014

The hardest part of the care plan in reality is the assessment. Getting a way to maximize assessment in a short period of time. Nurses do this everyday with multiple patients. It takes time to learn how to focus your assessment and get the "right" important information.
I have in my sig line a worksheet to help you focus that assessment.

I agree with this, but didn't think about it when I was typing my list -- I've been a medic for many years so have also gotten pretty good at assessments in a short pt encounter.

One of the other problems that I see from the posts given on this thread (as well as encounters with other RN students at clinicals) the answers are going to change based on what is expected on a care plan per the program and instructors requirements.. Ours is very details and usually takes at a min of 2 pages - with condensed information - while I've seen other programs care plans that were very much more basic and didn't require the same level of detail that ours did..

It would be difficult to evaluate what everyone is saying as different challenges without seeing example care plans as a reference -- someone mentioned that it only took them 30 mins to prepare a care plan -- really? there is no way physically possible in our program to look up 3 different nursing Dx and type the interventions with the rationals.. plus the shift goals and assessment of the goal in 30 min.. 1 nursing Dx in a 30 min window yeah.. but not 3 :)

smf0903 · Apr 28, 2014

@203bravo...yes, when I said ~30 minutes, I meant ONLY for the single care plan (one diagnosis). No way do our multiple diagnoses care plans get done in that amount of time LOL! :)

Episteme · Apr 29, 2014

Good feedback...

It is difficult to compare your experiences directly. Nursing Care Plans can be formulated and used for a variety of different purposes... including things like APA format and writing skills. Or Evidence Based Practice. Or to reinforce National Patient Safety Goals or Nursing sensitive indicators yadda, yadda, yadda. They are just such robust instruments for evaluating what is going on in a student's head.

One thing that does keep coming up is that different instructors want different things and have nuances and ticks and stuff. I think that's because the "Nursing Process" is a lot like "Jesus". Here's what I mean. The nursing process is really what professional nursing is. It's a thought process. Real nursing goes on between your ears, not at the end of your fingers.

So... anyhow... all instructors believe in and preach the nursing process. Similarly, all westerners pretty much know who Jesus is. But you put a rabbi, a Lutheran, a Mormon, a Baptist and a Catholic priest in the same room and... it's off to the races!

The nursing process and nursing educators aren't that extreme, actually. But that could explain some of the variability.

Pink Magnolia, BSN, RN · Apr 29, 2014

What was your last Care Plan about? (Case study? Actual patient?)

actual patient

Ineffective airway clearance r/t inflammation & constriction of bronchial tree

About how much time and how many books/references did you use to complete it?

30 minutes (for only one)

2 books

How many do your write in a semester?

about 21 (3 per clinical & for sim lab)

What major sections make up your care plan forms.

medical Dx, nursing Dx, objective/subjective data, goals, planning, interventions (+rationales), and evaluation (basically ADPIE)

What did you find most challenging (difficult or confusing) about the assignment?

The most challenging is not HOW but WHAT. I always have trouble finding the best dx for my patient. I want to choose the priorities.

Advanced Practice Columnist / Guide · Apr 30, 2014

What was your last Care Plan about? (Case study? Actual patient?)

Gee, I don't remember since it has been so many years ago (I graduated BSN in 1991). I'm pretty sure it was on an actual patient I was assigned to in clinicals.

What were the learning objectives for that assignment? (IOW: What was your instructor looking for?)

I think instructors look for how well the student thought through the Nursing Process. You have to show organized thinking in how you would translate the patient's clinical presentation into Nursing Diagnoses and Interventions that make sense, hence, we are required to add a rationale for each intervention.

About how much time and how many books/references did you use to complete it?

I used a book with sample Care Plans and whichever textbook we were using for the particular semester. It took me an hour or two to finish. I'm very detail-oriented. My Care Plans got A's.

How many do your write in a semester?

1 or 2

What major sections make up your care plan forms. AND, finally...

Nursing Diagnoses, Subjective and Objective Findings, Nursing Interventions with Rationale, Evaluation.

What did you find most challenging (difficult or confusing) about the assignment?

Figuring out Nursing Interventions. I tried to avoid adding medical interventions in that section because our instructors back then prefer for us to use specific nursing-focused tasks and that can be hard when most of what we did on patients were focused on medical management.