About Me

undergrad RN
I'm a twenty-something Canadian student. After stumbling through a few years of college, I finally managed to get into the nursing school of my dreams, where I hope to graduate in 2012 with a nursing baccalaureate degree. I want to offer an honest look into how a modern nurse is educated, both good and bad. Eventually I hope to compare my education to my day-to-day career and see how it holds up. Whatever happens, it should be somewhat entertaining. Find me on allnurses.com!
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Monday, April 19, 2010

Care Plans

Blech. I've written 3 care plans this year, one for each of my clinical rotations. They are essentially full-sized research papers worth a huge chunk of my final grade.

Care plans are fickle creatures. We never had a proper care-plan-class, which really irritates me. I mean, I had to take English (again) to ostensibly learn how to write papers, but I don't have to take a care plan class to learn how to write care plans? Especially when I have never seen a care plan in my life and said care plan has the same impact on my final grade as any research paper had?

So because the learning curve was kind of steep (last semester we were briefly introduced to the nebulous concept of writing a care plan, and all of a sudden this semester we were told to Write A GOOD One Because It's Worth 30%), I had a lot of self-learning to do. Something I do frequently, it seems...

As part of the framework required to write the care plan, my school assigned the following guidelines:
  • Patient's age, gender, marital status, religion, allergies, admission date, diet, activity, code status
  • Current medical diagnoses including pathophysiology
  • Past medical hx and health problems
  • Applicable surgical/other procedures and their most common complications
  • The patient's context of health, including (my personal favorite... lol) ye olde Determinants of Health and the principles of Primary Health Care
  • The patient's developmental and social hx, including family and their influences on the pt's health
  • Ordered tests, treatments, and interventions, including agency protocols and policy
  • Recent diagnostic tests and results
  • The teaching/learning needs of the pt
  • How other members of the interdisciplinary team are involved in pt care
  • Strengths & capacities of the pt
  • Ordered medications including rationale, classification, side effects, and nursing considerations specific to the patient
  • And, finally, 3 primary patient needs to address in the care plan. Each must include:
    • Nursing diagnosis (NANDA stem, etiology, and manifestations)
    • NOC labels 'SMART' goals (specific, measurable, appropriate [person-centred], realistic, & time limited
    • Nursing interventions (NIC labels)
    • Rationale
    • Evaluation
Of course everything must be cited and referenced in APA (barf) format. Throw in a paper introduction, a patient introduction, and a conclusion of some kind, and you are looking at around 5,000 words. My psych care plan came in closer to 6,000 after including DSM axis information and background info on my patient's diagnoses.

Ah, Health Determinants. My school freakin' LOVES them. The Public Health Agency of Canada has a veritable GOLDMINE of quotable information on each determinant. If you're a Canuck student like me, check it out. Even if you're not, I'm sure there's something quotable there for you as well. Or maybe your own health agency has something similar.

The first care plan I wrote was on the "where's my bag? it has urine in it" patient from Unit 3L. Given how poor of a historian she was (dementia and decreased LOC), I didn't get a lot of her Health Determinant information. That cost me very dearly because according to our care plan rubric I MUST have the information. My instructor told me that I should have called her social worker or nursing home to find out more. I can see the conversation now: Hi, I'm UgRN. I'd like to pump you for information one patient out of your stacked caseload. Right, this information will have no relevance to her patient care because I'm not assigned to her anymore. But I need everything you can tell me in great detail because I am trying to ace this paper. Uh, no thanks.

The second care plan I wrote was on my elective hip surgery patient. Since he was cognitively intact, I was very excited to get a quality health history on him, but he wasn't much for talking. Luckily he asked me if I could email a questionnaire to him. Why, yes! SO much easier to just fire off those questions into cyberspace. He wasn't lengthy in his replies but at least I had something to go on. My instructor gave me bonus points for effort. Unfortunately she docked many marks because my care plan wasn't individualized enough to the patient. Strike two....

The questionnaire I made up was pure genius, though. I think I may use it again. Such gems as:
  • How would you rate your overall health status, with 1 being “very poor” and 10 being “excellent”? 
  • How much control do you have of your overall health? For instance, do you have access to the food you would like to eat, can you live where you want to, can you buy the medications you need? 
  • Please tell me a little about your children and your family dynamics. 
  • How has your heritage impacted your life as a Canadian? Do you have any cultural preferences? 
  • How have you overcome the bigger obstacles in your life? How did you cope? Did you have people you could rely on? 
The THIRD care plan (the one I was up all night doing a week ago) I wrote was on a legally blind patient in my psych rotation. I went to town on this one. I wrote the lengthiest summaries I have ever written and threw everything I could into the Health Determinants section. I then got 4 care plan books, my psych text, and the DSM-IV manual and proceeded to cite the SHIT out of it. Here's an example:
Physical environments. “The physical environment is an important determinant of health. At certain levels of exposure, contaminants in our air, water, food and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness and gastrointestinal ailments (Public Health Agency of Canada, 2003).” Jane has lived in Alberta for her entire life. The urban health regions have a much lower mortality rate for all causes of death for females from 2006 to 2008. Calgary has 419.43 deaths per 100,000 population and Edmonton has 427.59. The mean for Alberta is 443.65 (Alberta Health and Wellness, 2009). Jane’s physical location is positively impacting her health simply by virtue of health accessibility and active living opportunities.
I also got very detailed with my NANDA-specific nursing diagnoses (this was the first of 3):
Priority need. Ineffective coping related to loss of vision, personal vulnerability, perception of inadequate control, impaired adaptive behaviors, and problem solving skills, as evidenced by flat affect, social isolation, inability to meet role expectations, poor self-esteem, uncertainty about choices, and deference in decision-making. Jane’s history of dependent behavior is making it a challenge for her to adjust to life as a visually impaired person. It is easier for her to surrender decision-making responsibility to John and rely on him to perform the roles of partner, guide, and caregiver than to accept her blindness and find ways to manage with it and go on with her life. Jane instead copes by isolating herself and being the passive member of their relationship.
Apparently it paid off, because I scored 18.9/20 on it. I was floored. I NEVER expected that kind of mark on the last paper of the year. Yay, me!

Nursing Care Plans: Nursing Diagnosis and InterventionIf you struggle as much as I do with writing care plans, I STRONGLY recommend investing in a good care plan book. I really, really like Gulanick & Myers' Nursing Care Plans: Nursing Diagnosis and Intervention. The book was very well rated on Amazon and with good reason. It has the NANDA, NIC and NOC labels for all included care plans as well as oodles of online resources and plenty of interventions and rationales. I am very happy with it. So is everybody who keeps 'borrowing' it every time a care plan comes due. At $40 it has been way more valuable to me than the freakin APA guide I spent an embarrassing amount of money on in first year.

Also keep in mind that your campus library, hospital library, and often hospital unit have really good (and really specific, in the case of on-unit material) references available. That's how I found specifically psychiatric care plans such as the one I used for my 'Ineffective Coping' diagnosis.

Another really good free online source I found is the Care Plan Constructor which I have linked on my Resources list. It's not as detailed as a book would be, but it gives you some more interventions and rationales to cite. It's also faster to navigate than a book, IMO, so it can be really handy to peruse for diagnosis ideas.

If I think of any other good things to add, I will. If you need help with your care plan I'd be happy to try. If you have any questions, fire away!

4 comments:

nurseXY said...

Oh holy hell I hate care plans.

Aside from the mosquito, I'm not sure there's a more useless creation on this planet.

undergrad RN said...

Truth.

I could understand if we made care plans BEFORE we were assigned a patient. But after? What point does that serve?

But I have never heard of a place that actually uses care plans in day-to-day patient care. Certainly not 30 pages worth.

I am killing the rainforest.

Chris said...

Dude, get this. Clinical is work NOTHING toward our final grade. Care plans = nothing, skills = nothing. The only thing we're graded on are exams... which don't follow any proper/standard format. I'd prefer 30 care plans a semester over this.

LostPorkChop said...

Care plans have never served a REAL purpose in patient care. No one in my 20 year career from co-worker (RN) to social worker to resident to medical assistant to physician to surgeon to anesthesiologist to lab tech OR even an actual patient has communicated to me about said patient care in any "standardized nursing language" nor shown any hint that they know we have this valuable thing called a care plan that would open their eyes to the specific plan with which to carry out said patient care. Nurses don't even communicate this way for crying out loud. I dare you to discuss your patient's "altered fluid balance" on rounds. Bring a flip video recorder so you can capture the absurd looks you will get from the "medical team". Point of nursing should be emphasis on being part of the medical team. A necessary role and function. Screw "our own body of knowledge". No profession exists in a vacuum. This "taxonomy" is made up crapola. The language of medicine is that of science. Fluid volume overload is a way of saying something but so as not to say anything specific so why the heck would anyone say this? Unless, you are teaching undergraduate nursing that is. Nursing has gotten so detailed and technologically specific that one removed from the acute care environment is certainly the best choice of nursing educators to be teaching "nursing". Good God we are a Bunch of bungling morons to be perpetuating the fraud of NIC NOC & NANDA instead of focusing on the pathophysiology of disease and the treatments there of, and the very difficult and technologically specific ways in which to carry out these treatments without killing anyone in the process. I'm so sorry to all you young and dedicated nurses in the making. I didn't have the guts to stand up and scream for our liberation from this time sucking waste of precious school days. I am but one person. I did do my masters thesis on evaluating if anyone spoke in terms of NIC NOC or NANDA in report at shift change. No one did. I was not aware of my political misstep in this regard. Suffice it to say that the Emperor may be naked, but no one gives a damn. So, suck it up, pretend you take this whole thing seriously my young friends. You can forget about this when you start your first job and there actually learn something. Until then, assume your blog and your complaints are being read by the administration, so be sure to comment on your strong condemnation of my contribution to this discussion. Dissent is akin to lack of devotion to this thing called Nursing and once branded a heretic... Well, you might need to move a few states away and start over.
Also, young ones--- Do not ever discuss your interest or participation in continuing your degree or advanced degree at work. Kiss of death. This is seen as another slight and shows your blatant disregard for your profession. Funny huh?

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