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.”
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.