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What's in a Care Plan?

I came across a meme that said:

I ain’t met a nurse yet who looks at a care plan before taking care of a patient

But whatever….

And maybe in my first year of nursing, I would have read the post, laughed a little, and kept scrolling, but today, I pondered it. Is it funny? Sure. Can I understand where it came from? Yes.

In my 2-year nursing program, we never had to do lengthy care plans like the other 2 local schools did. When I had clinicals, we had paperwork that utilized the concepts of care planning with writing nursing diagnoses and interventions that went along with it, but I never had to create a 30+ page document that was put together as a care plan assignment, and for that I am grateful. I might have continued to scroll past memes like this without reflection if that were the case.

I will say that hospital charting has made nursing care plans something that it is easy to click your way through and not think about or take pride in, if you will. And the meme is accurate in the sense that I don’t open the care plan and review what “diagnoses” are on the plan and what interventions have already been charted on by my coworkers. I certainly appreciate that the care plan is part of “necessary” charting that demonstrates the need for skilled nursing care as part of billing for a patient’s stay in the way that America has set up the healthcare system.

I will say in my reflection, I was able to ponder the fact that when I am caring for a patient, I initially receive general report on why the patient is with us, what safety precautions go along with the patient, what medications they are on, if they have any medical diagnoses, etc. I also receive a report of the last shift (or two shifts) and what the day-to-day of the patient’s stay has been like. With all of this gathered information, I know in my mind what tasks I have to accomplish (because certain other charting is also required of me), but I also am care planning in my head. How am I going to approach this patient, do they have specific sensory needs, do they need nursing care because they have a diagnosis such as diabetes, and I need to watch out for their blood sugar or count their carbs, are they really homesick and tearful but also presenting in an angry fashion, as anger generally causes those to avoid you when crying causes people to approach you, and who wants to cry in front of a stranger? Not usually me, that’s for sure. All of these considerations are care planning. Does my brain think “ineffective coping” and which “intervention” boxes I’m going to check underneath that diagnosis when thinking of the homesick kiddo, of course not, but I do provide nursing care and I do generally have a tentative plan for my day with all of the kiddos I am responsible for at that given time.

If I continue to teach nursing students in any fashion, I hope to be able to have these sort of reflection type conversations, to encourage brainstorming that no matter how the facility you work for makes you chart and how silly or box checking it may seem, having a nursing practice that you feel proud of based on care you provide does involve a care plan, even if it isn’t in the way the meme is poking fun at.

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