Sean was recently whining a bit about care plans, fortuitously the same day I was mulling them over while I worked out. Why was I doing this? Who knows. I haven’t made one since school, at least not formally. What I was thinking about, though, was that there is some method to this madness, because the nursing process was drilled so thoroughly into my skull that I do use it with each patient. I have little mental diagrams with a problem or two to address per shift. Do I think nursing educators take this to an unreasonable extreme? Obviously. Those NANDA diagnoses are a menacing time sink.
My third-semester clinical instructor did it right. She was a drill sergeant, but she drilled us on things that mattered and not on time-consuming idiocy. We could scratch a care plan on the back of a napkin and talk her through it, and if it made sense and hit the relevant points we got credit. That semester I learned a lot about being a good nurse and less about being a good nursing student—a distinction often missed in nursing education.
My original point, though, was that especially as I’m starting in my new job area I have to use these formal constructs to think through things because it’s not automatic yet. One happy circumstance of nursing is that we have frameworks to go on when our first impulse is to gape and scratch our heads: Assess. Diagnose. Plan. Implement. Evaluate. (Important addition to “Assess”: you can buy time by auscultating the patient’s chest for a long time. Look thoughtful. It gives you a minute to ponder, and they don’t talk to you because you’ve got a stethoscope in your ears.)
We in fact have all kinds of frameworks. We’ve got ADPIE, ABCD, AMPLE, MONA-B, and all kinds of other treasured systems. One of my favorite nurses at my old job, an ER/ICU nurse, used to say that much of nursing is common sense when you cut through it all. If someone isn’t breathing well, you have to fix that. If they’re bleeding, you find out from where and stop it. If they have bad pulses, you have to fix that because their organs aren’t getting perfused. People with natural common sense are probably baffled at my need to state this, but I’m very cerebral and tend to get ahead of myself sometimes, thus unnecessarily complicating situations. More to the point, fixing the common sense things first, regardless of the urgent needs alongside, can give me a minute to “take my own pulse,” calm down, and more calmly orchestrate the situation.
On the floor, I used to joke that my priorities were having clean, breathing patients who weren’t falling. Those are going to have to change in the ER. I mean, I still want them breathing, but “clean” is going to have to take a back seat…
