Fluff and Stuff

There are many reasons to write a thorough and complete care plan but thorough and complete doesn’t always equate to long. This is especially true where orders are concerned. There exists an overly cautious attitude among some nurses that drives them to include every possible order and intervention that the patient may ever need in this lifetime or the next. The end result is a six page document with crucial information buried between the ‘fluff and stuff’.

Here are some orders I see that make me wonder how they ever hit the care plan.

1. Draw Lab per MD Orders. Why put that in your orders unless you have orders? If you have orders, simply write them. If you do not, then you will when you get the orders. Who else besides the MD would write lab orders?
2. Teach Diabetic Care including use of glucometer, diabetic foot care, sick day care, rotation of insulin sites, diabetic diet, importance of Hemoglobin A1C, causes of diabetes, importance of exercise and rest, signs and symptoms of hyper/hypoglycemia to report to MD and SN and to report blood glucose levels greater than 300 or less than 50. That is the abbreviated version. It is my opinion that if we include in orders to teach Diabetes care, a responsible, educated nurse acting according to best practices will include all aspects of diabetic care relevant to the patient during the episode. Notice the reporting parameters are buried at the end of the order, easily missed or difficult to locate. The worst part of this order is that it is a daunting task to perform in a single episode assuming the patient has comorbidities. Our patients are not enrolling in nursing school. It seems to me that the nurse who wrote this order didn’t consider assessment data and limit orders to the patient specific needs.
3. Weigh patient weekly. Generally speaking, this is a good order for a CHF or renal patient. It only becomes a problem when the patient isn’t seen but once every other week. A better order is to weigh the patient each visit and to teach the patient to weigh self on days between visits.
4. Report weight gain of 3-5 pounds. Which is it? Three pounds? Five? If I were playing semantics, I could argue that the only weight between three and five pounds is four pounds. But, surveyors do not enjoy word games as much as I do. A better order is to report weight gain of greater than X pounds with X being determined by the original weight of the patient, the stage of heart failure and prior history.
5. Report weight gain of greater than X pounds. While this is decidedly a better order than one with a range it is still not perfect. Consider my client who called me crying. Like me, she was an old Cardiac Intensive Care nurse. Her patient had strict parameters to call for a weight gain of three or more pounds in one week. Over the course of the episode, the patient put on one or two pounds a week. When the patient was admitted to the hospital, the patient had gained over 15 pounds. By placing the baseline weight on the care plan near the parameters, the nurses have additional information to make decisions. Additionally, a weight chart posted near the patient scale will show trends.

I like clear and concise orders. But truthfully, what I like is really not important. What is important is that our care plans are useful documents for guiding the care of nurses taking care of patients. Even surveyors can’t top that reason for writing clear, concise and individualized care plans.

As always, your comments are welcome below. Any other orders you find useless and can add to my list will help both me and your colleagues.