For most nursing students and new nurses, the thought of doing a nursing care plan can be terrifying! So many things to think about; a sick patient, wondering how you will come up with proper interventions, and sleep deprivation. Beating the fear of nursing care plans can actually be quite simple if you know exactly what they are!
Beating the Fear of Nursing Care Plans: What Exactly Are They?
First, let’s take a look at what nursing care plans are. In order to do that, let’s take a look at nursing as a whole.
Nursing was not originally a “profession” as we see it today. It was rather disorganized when it began back in the 1800’s. Hospital wards were dirty and nurses labored long hours just to keep people alive, which wasn’t very effective and many patients were lost.
Our “mother of nursing” Florence Nightingale saw the need for nursing standards. She came up with nursing interventions that can assist the patient with healing such as; cleanliness and hand washing, fresh air, light, food, etc. What she found was less patients were dying due to hospital acquired infections or their illnesses. Less were dying and more were recovering.
Nursing care plans are a standardized version of what Florence Nightingale practiced to improve patient outcomes. The actual definition is: “the nursing care provided to a patient, based on an actual nursing diagnosis.”
Are you diagnosing the patient with an illness? Nope. The doctor is in charge of that. You are merely identifying the patient’s biggest needs as a diagnosis. For example:
Medical Diagnosis by Doctor: Chronic Obstructive Pulmonary Disease
Nursing or NANDA Diagnosis: Ineffective Airway Clearance
Okay, so you have found a nursing diagnosis to go with your medical or doctor’s diagnosis. Great! Then you ask, “now what?”
This is where beating the fear of nursing care plans comes into play.
How in the World Do I Come Up with Interventions?
Made very simple, nursing interventions are nursing orders for care to make your patient comfortable and increase the body’s ability to heal itself! What you order for care on your nursing care plan is anything you can do without a doctor’s order, plus include implementation of the written doctor’s orders.
Things you can order within your scope are some of the very same things you would do when you or a family member is sick at home with a cold. Just ask yourself these questions:
- Do you need to call the doctor for a prescription for tissues? Nope.
- Do you need an order to humidify your own room air? Nope.
- Does the doctor have to write a prescription to elevate the head of your bed? Nope.
- What about deep breathing and coughing? Nope, doesn’t need an order.
- Does the doctor have to write orders for cough syrup? In the hospital, yes. But you can write “per doctor’s orders” into your interventions and it’s okay.
Just make sure that if there are any interventions you are unsure about or contraindicated by a doctor’s order, ask your nursing supervisor.
Here are a few sample interventions for “Ineffective Airway Clearance”:
- Elevate head of bed (Nursing)
- Give breathing treatments every four hours per MD order (Doctor)
- Offer tissue and encourage patient to cough up secretions (nursing)
- Administer oxygen per MD orders (Doctor)
- Encourage patient to turn, cough and deep breath every two hours (nursing)
Once you get the hang of it you will find it is really pretty easy! Just think of things you would do at home. Another example; Unable to keep fluids down? Offer frequent sips of clear liquids. (Keep in mind that is according to the doctor’s dietary orders.) Just make sure to ask if you are unsure what is okay to list as an intervention and that you always check the chart for MD orders. Any MD orders need to be noted in your care plan “per MD orders.”
So, What Now?
Now you have the info to make developing a care plan a bit more painless, you need to know where to start. A nursing care plan begins with your patient. Here are the steps to take when developing your care plan:
The first thing you need to do in developing your care plan is look at your patient. Do your assessment and from this you can pretty much determine what they need right away. Now there may be a few “sneaky” things that don’t pop up right away and care plans can be changed as needed.
#2 Read your Charts
Bored on nightshift or done with your med pass and charting? For your reading pleasure, pick up your patient’s chart and read it! While it may not be the latest novel about love or mystique, it may lead to some great clues about your patient’s needs. Past medical history, things that have worked for this patient before, and possible things you may need to alert the doctor on are all things you need to know.
#3 Look Over Doctors Orders
Read them twice if you can and double check them for errors. You have to advocate for your patient and you wouldn’t want a nursing care plan you developed to help your patient harm them in any way. Make sure your interventions are consistent with the doctor’s orders. Don’t implement any treatments or interventions on a patient unless you are absolutely comfortable. If you see an order for “Give increased fluids” on a patient with congestive heart failure, it is reasonable to call the doctor and ask if it should have been a fluid restriction.
#4 Listen in Report
Good Morning! Oh the joys of nursing! Exhaustion on your third twelve-hour shift and you can’t hold your eyes open in report. Nodding off in report can be easy to do and detrimental to knowing things you need to put in your care plan. The day nurse may be reporting that she noticed increased secretions on your COPD patient with pneumonia at the end of her shift. This will be something you will need to address first thing. Grab a strong coffee, or two, or three!
#5 Ready, Set, Care Plan
You made notes in report, you did your assessment, and checked your orders. Now it’s time to write it or type it into the EMR. Just remember, if you have questions about an intervention please speak up and ask your “nurse guru care plan expert extraordinaire” on your floor, your nursing supervisor, or your instructor!
Hopefully we have helped you beat your fear of Nursing Care Plans! If you want to learn more, please check out our article on Most Important Nursing Concepts. If you are looking for something a little lighter, have a laugh on us!