A written “Nursing care plan…serves as a means to document changes in a patient’s condition” (Medi-smart.com). Writing care plans are at the top of the list for causing major angst in nursing students throughout the years.
I remember those days in nursing school back in the late 70’s. We had to write care plans that began with phrases such as ‘Alteration in’, ‘Decreased’ and ‘Increased’. We did not have computers for research, nor standardized, pre-printed care plans.
The term ‘nursing diagnoses’ was not widely used then as it is now, we were just learning the classifications in the 70s. In 1982, NANDA was formed.
The NANDA International Board believes that:
• Nursing diagnosis is seen as an essential component of any professional nursing/client interaction
• NANDA International is recognized as a major contributor to nursing knowledge development through the identification and use of concepts that are the building blocks of nursing science.
• NANDA International is recognized as the leader in development and classification of nursing diagnoses. (About NANDA International, 2008)
“Without a specific document delineating the plan of care, important issues are likely to be neglected. The first step in care planning is accurate and comprehensive assessment” (Sox, n.d.).
A patient admitted to ICU for a brain tumor had an order for neurological checks every 2 hours. He went to surgery for excision of the tumor but when he was readmitted, the doctor ordered neurological checks every hour.
The nurse should have increased those neurological checks to every 15 minutes until the patient was stable; neurology patient’s condition may change rapidly. The patient was only awakened every hour because, according to his nurse, he was very sleep deprived. Unfortunately, the patient slipped into a coma in between the hourly checks. He never woke up.
Therefore, the number one task is using resources available to learn how to perform complete assessments. If you know the disease processes, then you know what symptoms the patients will have and the interventions required by doctors and nurses to alleviate them.
Think about what risks are associated with certain disease processes and what interventions from the nurse are indicated. Such as, if a patient is on bed rest, nursing care would focus on skin integrity, preventing breakdown, keeping clean and dry, and preventing pneumonia.
It is especially important to devise care plans for discharge teaching and home care. This will help all nurses to follow up on the teaching plan.
We had a patient who required admission every 2 weeks for exacerbation of asthma. After careful questioning, we learned the patient always burned trash, leaves and wood in a barrel in his yard. After teaching the patient causes for his exacerbations and how to use a peak flow meter, his admissions greatly decreased.
An elderly woman was admitted for failure to thrive; 2 days later the nurse found a decubitus ulcer on her coccyx that was not documented even by the physician. Same scenario when a patient was found to have a bread bag as his colostomy bag after two shifts.
These are extreme cases when a patient is admitted during a change of shift or the nurses were “too busy” for a complete assessment. That does not excuse these omissions by any health care professional.
You will notice some experienced nurses rarely have to write out care plans. We used Kardexes to convey nursing and physician orders but problems developed when nurses and clerks failed to update or put new orders on the cards.
For new and student nurses, be aware that learning to write care plans will greatly improve nursing care. With nursing orders, you may add vital signs parameters ordered by the physician and report any vital signs out of those parameters.
Keep in mind that if a physician orders vital signs every shift or every 4 hours, you can increase the frequency if needed. For example, a patient has a fever but the doctor only ordered vital signs every shift; you want to increase the frequency and even order vital signs every 4 hours.
You may have other diagnoses to add or are required to list in a different manner on your care plans but here are some examples:
Physician’s diagnosis: Congestive Heart Failure
Nursing diagnoses:
Fluid overload related to CHF
Shortness of breath related to fluid overload
Activity intolerance related to fluid overload
Nursing orders:
Strict intake and output–report a urine output less than
30cc an hour. Make sure others are aware because
physicians will write orders based on the totals.
Weigh every morning at the same time and before the
physician makes rounds.
Schedule care with breaks in between
Gradually increase activity as tolerated, stop and
allow patient to rest and catch his breath if needed
Physician’s diagnosis: Angina
Nursing diagnosis: Alteration in comfort: chest pain
Nursing orders:
Assess for chest pain every contact
Document description, location, intensity,
onset, precipitating factors, any radiation,
other related signs and symptoms
Allay any anxiety or fears by explaining
treatment process
Vital signs every 5 minutes during episode
change frequency or check as ordered. Check oxygen
saturation with vital signs
Medicate per order and assess for effectiveness
Administer Morphine, Oxygen, Nitro, and
Aspirin: MONA as ordered
Assure patient use medication properly-place
under the patient’s tongue and stay at the
bedside during angina episode
Perform an EKG if available
Notify physician stat if pain not relieved after three
Nitroglycerin tabs or as ordered
Be prepared for possible transfer to ICU
Physician’s diagnosis: Sacral decubitus
Nursing diagnosis: Alteration in skin integrity
Nursing orders:
Develop and post a turn schedule, use draw sheet
Keep skin clean and dry: use condom catheters or
request foley catheter if patient is incontinent
Medicate for pain if needed. Assess and reassess
notify physician if analgesic is ineffective
Encourage p.o. intake–consult with dietician
Consult with case manager and/or social worker if
placement required on discharge
The problem list “may actually include patient/resident strengths as well as family/relationship problems which are affecting the person’s overall well-being” (Sox).
A dying patient assigned his ex-wife to act as his power of attorney for healthcare but his 2 sons and daughter (who never really liked her as a step-mother) wanted to contest her decision to discontinue treatments (based on his wishes) thereby prolonging the patient’s demise. Of course, the ex-wife was very hesitant to discontinue treatments without their input.
The siblings were estranged from their father for over a year due to his alcoholism. They wanted the sole responsibility for the decision. The patient’s dayshift nurse immediately notified the doctor, social worker, case manager, and head nurse of this dillema and formed a new nursing diagnosis based on family dynamics issues.
This communicated to other nurses to observe, report if necessary, and document all interactions. A meeting was formed with the ex-wife, daughter and sons, all treating physicians, the primary nurse, the patient advocate and other members of the interdisplinary team.
After reaching a final decision and all family members were aware he would not recover, the patient was allowed to die with dignity. This intervention was coordinated by the patient’s primary nurse.
There may be times when changes occur on specific shifts, each nurse will be required to assess and enter a new nursing diagnosis. Maybe the ancillary person noted the patient’s appetite has gradually decreased, especially on the evening shift. The evening shift nurse may enter a nurse diagnosis and consult the dietician to see the patient in the morning. On shift report, the dayshift nurse will be asked to follow-up on the consult.
As you can see, nursing diagnoses and orders are an intrinsic part of caring for our patients in a holistic manner. Nursing care plans are essential tools for communication between each nurse assigned to a specific patient. Each nurse will know the issues and intervene appropriately.
Responses to treatments will guide the nurse to reevaluate the nurse orders, make changes, update and document findings.
So do not fear when you hear the words “writing care plans” because as you gain more experience, the planning of care will become routine. However, you must document to the problems, whether they are on going or resolved and communicate them during report and through documentation.
Using these techniques will hopefully help to understand and make writing care plans easier.
References:
About NANDA International (2008). http://www.NANDA.org/html/about.html
http://www.Medi-smart.com/carpel.htm
Sox, Holly F. (n.d.) What is a Care Plan. www.careplans.com
