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Care Plans: Worthwhile or Worthless?

Care Plans: Worthwhile or Worthless?

Beth Anderson, RN BSN

You can find some lively debates on the value of writing care plans and using nursing diagnoses. Some argue that they are a waste of time and not very useful. Others argue that they are absolutely essential to advance the field of nursing. The bottom line is that if you are a nursing student, you need to know how to write one because chances are, you will be given care plan assignments on a regular basis.

So what do you need to know about Care Plans?

First of all, you need to know what one is. Here’s the Wikipedia definition:

“A nursing care plan outlines the nursing care to be provided to a patient. It is a set of actions the nurse will implement to resolve nursing problems identified by assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.”

It’s basically an outline of the care you intend to give to the patient, and the rationales behind that care. It describes exactly what needs to be done for the patient and why, from a nurse’s point of view, and it does this by using the nursing process. The easiest way to begin is to break the nursing process down into a series of questions:

Assessment – What does the patient look like?

In this step you will use your assessment of the patient to describe their current state. You will describe what it is about the patient that is causing them to seek medical care, or causing them to be hospitalized. For example, if the patient is in pain, you would describe the pain in your assessment: “Patient reports pain at the incision site at 7/10 on the pain scale.”

Career and Educational Information

Diagnosis – What is the patient’s problem?

In this step you will create a nursing diagnosis for the patient. Don’t confuse the nursing diagnosis with a medical diagnosis. A nursing diagnosis describes a patient’s response to a condition, rather than naming the patient’s actual condition. For example, a medical diagnosis might be “Thrombocytopenia (or a deficiency of platelets in the bloodstream)” and a nursing diagnosis would be “At risk for bleeding.”

Plan – What are you going to do about it?

Your plan is what you intend to do for the patient. If a patient is one day post-op then the plan might be to get her out of bed to a chair two times a day. If she has pain issues then the plan would be to administer pain medication and then reevaluate her pain level.

Implementation – What did you end up doing about it?

This is where you carry out the above plan. What were your actions and how often did you do them?

Evaluation – Did your plan work?

This is where you describe your patient’s response to your intervention. Take the patient who was in pain. You might say, “Patient received 2 mg Morphine IV and patient is now reporting a pain level of 1/10 on the pain scale.”

You might be saying to yourself at this point, "This seems like a lot of documentation. Is this actually something that I will be using in the “real world?”

In a sense, the answer is yes, you will use a care plan every time you see or care for a patient. The difference between writing a care plan in school and using one in your professional practice, is that in the real world, the flow of the care plan is going to seem much more intuitive, and it will be easily integrated into your charting.

Let’s put this all together and apply it to a patient who has come to the hospital with Pneumonia. Here’s an example of what his care plan would look like:

Assessment: The patient has SOB (Shortness of Breath) on exertion.

Diagnosis: Altered Respiratory Status related to pneumonia

Plan: Administer 02 and check vital signs every 4 hours.

Implementation: The patient has been maintained on 2L NC (2 liters via nasal canula). Vital signs have been checked every four hours and have remained WNL (within normal limits).

Evaluation: Pt is able to get out of bed and sit in his chair without feeling SOB.

Mind you, this is only one aspect of his plan of care. A patient with pneumonia will probably have numerous interventions while he is in the hospital, and so you could include each of these interventions within your care plan. This may seem like a lot of work if you are a nursing student, and many nights you will find yourself staying up and writing these things before you show up for your 7AM clinical. (Hey – I didn’t invent the system- I’m just trying to help you get through it!) If you break it down into simple steps, it becomes a much easier process.


Would you like to submit a sample care plan? Please submit one or more to assist other nurses.



      

      

      
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  • Photo_user_blank_big

    kito4149

    about 5 years ago

    18 comments

    care plans make u or break u- nuff said

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    aabryan

    about 5 years ago

    24 comments

    This article is very insightful. I look forward to starting nursing school in the spring.

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    rhysjanus

    about 5 years ago

    12 comments

    I am a charge nurse in a rehab facility. We have 45 beds and about 1/2 are LTC and the other are rehab. I don't like the constant reviewing and updating that my job requires, but when that careplan is protecting me, I'm so glad I have them. We have a meeting once a week and review what needs to be updated and or initiated for all 45 of our patients. I think careplans are a necessary evil if you know what I mean.

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    clee123

    about 5 years ago

    8 comments

    Care plans are a complete waste of time in an acute care setting. The time it takes to write and maintain one is time we just don't have anymore. For pts whose average stay s THREE DAYS, it is a complete waste.

    However, there is some value to it for pts in a longer-term setting such as rehab or long-term cae facilities. In those setting, it would make good sense to have a formal plan for nursing care that includes periodic reevaluation.

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    rosanski

    about 5 years ago

    4 comments

    Goals should have a singular focus and implementations are not evaluated, only the goal is evaluated. Implementations assist the client in achieving the stated goal. Your simple examples might lead a student down the wrong path.

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    adaku

    over 5 years ago

    2 comments

    the care plan is good.educate nurses well on it.and enforce its implementation

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    scorpio80kg

    over 5 years ago

    18 comments

    We are doing care plans in school now and it is hard to get away from trying to use a medical diagnosis instead of a nursing diagnosis

  • Austin_and_me_max50

    rlsvaldosta

    over 6 years ago

    2 comments

    yeah but nurses are not allowed to use medical diagnosis in a care plan so it would actuually be, not r/t pneumonia but mabe r/t thick secretions ??

  • Dad_stuff_029_max50

    Done

    over 6 years ago

    362 comments

    Great reminder.

  • 007_max50

    tmims

    over 6 years ago

    20 comments

    i love this article......its very helpful. thank you to whom ever posted this valuable information.

  • Halolo_006_max50

    thejoe17

    over 6 years ago

    10 comments

    Nice of you to take the time to write this, even though it is explained several times and we all talk about these care plans it is good to get new views.

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    bpark51

    almost 7 years ago

    120 comments

    Care plans are vital as a guide to addressing the needs of each patient

  • 100_0608_max50

    heyjude1304

    almost 7 years ago

    464 comments

    Care Plan is very important for the CNAs, CMAs, and Nurses as well. It has all the information on most everything about a patient including Code Level Directive (resuscitation wishes) and "Dots" - fluid consumption, skin integrity concerns, diabetics, etc., Assistance with ADL's, ROM, Balance, and other instructions. When in doubt about how to take care of the patient always refer to the Care Plan. Any change/s that may occur on the patient during the tour of duty must be reported to the proper authorities and they have to make sure that it is reflected on the Care Plan.

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    DaMomb

    almost 7 years ago

    1242 comments

    gotpills, I think you said it well. There are books out there..."PC's for Dummies, Sodoku for Dummies, etc", so why couldn't someone develope a "Patient Careplans for Dummies"?

  • Photo_user_blank_big

    rew573

    almost 7 years ago

    10 comments

    I think this is a great way to explain care plans to students soetimes the way a person explains it makes all the difference in the world.

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