Since the whole ‘nurses don’t do care plans’ thing came up, I decided to Make A Post about it, because I’m bored and in bed by 20:30 and I still have the care plans I write in college because I am a Loser.
Our care plans involved: demographics (name/age/etc), admitting dx, full assessment, list of meds, stage of life (as per Erikson), labs, nursing diagnoses/interventions/expected outcomes, discharge planning, community resources needed (meals on wheels, vna, coumadin clinic, etc), discharge teaching, a nursing theory that we would use to provide that discharge teaching, and then we had to write a research paper 1-2 pages about a specific topic. Obviously as a nurse I do not write this research paper, and I don’t write out a full care plan each time, but I do have to write down/ use the computer about every other item on here (well, except maybe Erikson, but that’s usually used more for younger people as nearly all of mine are in the same stage of life….freakin’ old).
I always know name, age, most recent vitals, allergies, admitting diagnosis, medical/surgical histories, and code status before I even see the patient, baring an immediate emergency that day shift for some reason isn’t responding to (or, when on my 4th shift in a row and a patient I know very well is dead…). We luckily get most of this stuff on a rounds report printed out, but even if we didn’t, I would look it up. Important stuff (like one time my resident tried giving a patient morphine… who was allergic to morphine…. and pharmacy was just like “oh yeah we saw that, didn’t think it was anything serious”… it was).
While getting report, I always write down their most recent lab values as well as any alarming ones from their stay, within reason. An elevated INR 3 weeks ago isn’t a big deal, as long as they’re stable today. During report, the offgoing nurse should tell you what is being done for the patient, a full assessment of the patient, any med changes, and what the discharge planning for that patient is. Even if the patient doesn’t have one yet, “case management is looking for placement”, or “patient is being conserved”- discharge planning.
Next I write down all the meds that I will be giving the patient that night, and scan the list of meds they get on the other shifts. If I see that a patient is diabetic, I ask how long, because chances are a type II diabetic who is well controlled outside of the hospital doesn’t need me harping on about carbs while a newly diagnosed pasta addict needs lots of education. Anyone on coumadin, especially new afib-ers, need explanation and follow up about INRs and coumadin clinics and foods to avoid, shit like that. I don’t write it all out in a 7-page word document, but I do it.
I don’t research a nursing theory to base my shift off of, but I’d like to think that I know enough about health promotion, self care, etc etc that I can base my words and actions off a bunch of different theories. And when you know a patient that well, discharging them can actually be simple…. just know what you have to tell them, what to look for, when to come back, and they’ll be out of there lickety-split. Then write your discharge teaching nursing note.
The nursing diagnoses / interventions / outcomes is both part of our “care plan” tab on our assessment AND part of your nurse’s notes. If I have a high fall risk patient my nursing note ALWAYS includes the line “bed alarm on, safety maintained”. If I have a patient with COPD on oxygen that’s not their baseline, I ALWAYS write a note about titrating them down, stating what their pulse ox was and what happened when I turned it down, even if the note is “attempted to titrate off O2 and was unable because patient dropped to 87% on room air/ whatever I put them down to”. If your patient has an ulcer then you document wound care, skin care, turning and positioning- and if their skin is intact, you document that you turned them and cleaned them and sprayed barrier spray to KEEP IT that way.
You are doing care plans as a nurse. They’re just not as stupid and disconnected from your actual physical care as they used to be in nursing school (or how mine were anyway). I’m looking at one of the care plans I did during my first ever clinical rotation and, from the info, I can tell you exactly how I would have cared for this patient and what the doctors would/should have done for them.