Using Nursing Care Plans in Clinicals

Most often NOT written
1. Though some EMR’s require documentation
  1. IPOC = “Interdisciplinary Plan of Care”
2. Check facility policy
Happens by Instinct
1. Nursing process + Critical thinking
2. May not even realize what’s happening
Examples
1. Get report –> “blanchable redness on the sacrum”
  1. Immediately in your brain –> Skin!!
    1. Make sure you turn q2h
    2. Use barrier cream if they’re incontinent
    3. Careful when repositioning
    4. Make sure it’s still blanching at end of shift (or decreased)
2. Get report –> “+3 pitting edema and 1+ pulses in the feet”
  1. Immediately –> There’s a perfusion issue!
    1. Keep the feet elevated
    2. Assess edema and pulses
    3. Ambulate as able
    4. Evaluate blood pressure
    5. Possibly administer diuretics?
    6. Make sure it’s not worse by end of day
You may not fill out a form, but you are STILL planning nursing care

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Transcript

Okay guys, I’m excited to talk to you about what this Nursing Care Plan process really looks like in the clinical setting.

We talked about this in the first lesson, it’s so frustrating to hear nurses say things like “you’ll never using Nursing Care Plans in real life”… it makes you feel like you’re wasting your time, right!? Well what’s really happening is they’re just not doing it the same way you are doing it in school. I promise you, it’s still happening, it just doesn’t look the same. So I just want to reassure you guys of how important understanding Nursing Care Planning is and what it looks like in real life!

So, here’s the big thing to know – in actual clinical practice, most of the time we aren’t actually filling out any kind of template or form. It’s usually not written. Now, the one caveat to that is that there are some EMR’s or Electronic Medical Records that actually have a place to document your care plan – sometimes it’s even called the IPOC, which stands for interdisciplinary plan of care. A lot of times they’ll have a set of predetermined priorities with assessments, interventions, and goals that you can just check the boxes and say “yep, this is what we’ll do for this patient”. So – really just make sure you check your facility policy to see if there’s actually something you have to document.

So, if we’re not filling out forms and templates and we’re not actually putting this on paper. What’s actually happening? Well, what you’re seeing is the SAME process happening by INSTINCT! It’s just the nursing process, plus critical thinking, and maybe a little bit of experience thrown in, right? The truth is that these nurses who say “oh, you’ll never use a care plan in real life” actually just don’t realize they are doing it!! Let me give you some examples of what I mean.

You walk in for your shift and you’re getting report and the offgoing nurse says “oh, this patient has some blanchable redness on the sacrum” – so that means they’ve got some redness, but if you press your finger into it, it turns white – or blanches – that means it’s NOT a pressure ulcer… YET. So what happens in the nurse’s brain? That nurse is immediately gonna go – OH – a skin issue! I need to make sure I turn every 2 hours, might need to use some barrier cream, especially if they’re incontinent. I should probably be careful when I’m repositioning them so we don’t add any friction or shear – and I’m gonna keep a close eye on it to make sure it’s still blanching and not getting worse. Right? ALL of that happens in their head all at once, and all by instinct. They have data – they recognized a problem – they decided what to do about it and why – and they knew what to look for to make sure their interventions were effective. That’s a care plan! Let’s look at another one.

You get report that the patient has 3+ pitting edema and only +1 pulses in their feet. So right away, your brain goes – oh, dang! There’s some perfusion issues there. Let me make sure I keep their legs elevated, I may even try to get them up and walking around if possible. Oh, and I’ll see if the provider thinks some diuretics might be appropriate depending on what they’ve got going on. And, of course I’m going to be assessing that edema and those pulses to make sure it doesn’t get worse – I might even get a doppler to confirm the pulse, right? And of course, we know this might be cardiac related, so I’m gonna make sure I keep an eye on their blood pressure, too, right? See? It all happens subconsciously!

So, remember, while that nursing care plan may not actually be written down in any kind of special template – it is STILL happening. It’s just that it’s happening by instinct and subconsciously most of the time. The biggest thing I’ll say here, is always trust your gut about what needs to be part of the plan and loop anyone else in as needed. If you need a respiratory therapist, call them, if you need PT’s input, grab them when they come on the unit, if you think you need provider orders, call the provider. Trust your instincts when you’re planning the best care for your patient.

So in the rest of this course, we’re actually going to use the 5-step process we talked about to work you through some examples of common disease processes and how to put together care plans for those patients – so make sure you check those out. Now, go out and be your best selves today. And, as always, happy nursing!

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Nursing Clinical 360

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