HER FIRST NURSING CARE PLAN
The patient is the paper on which she writes.
He is young, a husband, a father, wiped out
(Not a nursing term) after a gastric resection.
The word, metastatic in the chart is Greek
to her. She misspells it—metastes. The links
between words, the body, and the person
who lives there are beyond her. To sound
like she has a clue, she copies strange
anatomical terms from the chart:
omentum, right colic gutter at hepatic flexure,
along the left gastric artery generalized
metastes (except liver).
She plans her care, cares about her plan
that speaks with a false conviction.
She plans to watch, count, ease,
flush, remove, monitor, offer, relieve, be
there, listen, encourage, pray, prevent, provide
care to meet every need. She is hungry for treats
from her instructor, like “Good work!”
She fills her plan with problems
the cancer has created for her to resolve.
Only when the moon peers through
the window, does she think about the patient
who doesn’t know what metastes means.
She wonders how everyone but the patient
has been told. Certain she is not the one to offer
such a truth, she sticks to her plan.
Imagine an evening in a campus library in 1973. A young woman is sitting at a round table with books spread out all around her—books on anatomy and physiology, a nursing fundamentals text, medical dictionary, lecture notes, and a physician’s desk reference to look up drugs. Besides the books, she has a notebook of information from her pre-clinical visit to the hospital where she saw her assigned patient for the next day. The notes she scribbled as she read his chart are copious and disorganized. To add to her confusion, what the chart said and what she learned from her observation of her groggy, post-operative patient weren’t the same.
She pulls out a spiral notebook in which she pencils lines with a ruler to make columns—five columns, to be exact. At the top of each page, she writes a heading for the columns: objective assessment, problem, validation, plan of care, and criteria of evaluation. The pages are blank except for the columns and the headings. It is her task to fill in the columns to comprise a plan of care for her patient. The sky will grow dark by the time she finishes her care plan.
My poem Her First Nursing Care Plan had its genesis in my memories of writing care plans late into the night and, at least at first, how overwhelming I found the whole exercise to be. The poem is written in the third person voice to indicate the universal nature of writing care plans. Anyone who has completed a nursing degree program since the late 1950s is familiar with what a care plan entails. In the 1970s when I was a student nurse, there were no computers in the hospital, patient charts were paper files, and for patients who were critically ill, their charts ran into several volumes. Speaking of volumes, we found all our references in books. We wrote everything by hand in the charts and our care plans. The format for today’s care plans remains very close to the one we used then. However, there was no taxonomy of nursing diagnoses. The first conference that created them didn’t happen until 1982 and wasn’t published in a book until 1990. There was less technology in the patient’s room and nursing station. We counted the drops that fell from an IV using the second hand on our watches to calibrate the flow. There were no cell phones that now give us access to all sorts of information in a flash. Interprofessional collaboration was a vague hope then, and perhaps still is for many in contemporary clinical settings.
The nursing process, the foundation of care plans, not only includes learning a mental model for addressing an individual patient’s needs but also translating that understanding into action and evaluation. The “action verbs” in the poem are all taken from my old care plans. There were more verbs I could have included, but even this short list is a lot to grasp. I kept some of my early care plan notebooks, so I have firsthand access to past instructors’ critiques, such as: You need to assess every need listed on the handout form to be sure you are getting them all; Not necessary to use pronouns and prepositions. Be more concise; I will expect you to be more thoroughly prepared than this in the next clinical session. Those comments and insights were sometimes painful, but always indicated how I could do better even though it felt like guesswork at times.
As a student, I understood that the sicker the patient was, the more there was to assess and plan for during a shift. In the real world of practice, nurses rarely take care of only one patient, so it is easy to see how “needs” or “patient problems” can pile up when taking care of multiple patients. In the poem, I decided to mention this aspect of what it means to balance the needs of patients against the human limitations of every nurse. Also, I was disturbed when physicians withheld critical information from patients about a diagnosis, particularly when it was one as serious as metastatic cancer. I sensed that patients should know about a bad diagnosis even though I didn’t fully understand what a life-limiting prognosis meant. Beyond that insight, I understood early on that it was not my place to share bad news like this. Perhaps this is why I became interested in healthcare ethics later in my career so I could better navigate these kinds of issues and speak up when I thought something was morally wrong.
Throughout my career, I learned to take what was on the page and organize the many practical aspects of patient care into a manageable whole—not every time, but most of the time. The poem is a reflection on my personal journey in nursing but also a broader invitation to readers to think about where they started and where they are today in their professional lives.
Amy Haddad, PhD, MSN, MFA, RN, FAAN, is a poet, nurse, and an educator at Creighton University in Omaha, Nebraska, USA. Her poetry collection An Otherwise Healthy Woman won first place in the Creative Works category of the AJN Book of the Year Awards for 2022. She is a member of Sigma’s Iota Tau and Gamma Pie at-Large Chapters.
Note: An earlier version of this poem was published in Taylor, C., Lynn, P., Bartlett, J. (2023). Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Edition, Wolters-Kluwer Health, Philadelphia, PA, p. 466. To read more poetry by Amy Haddad, visit www.amyhaddadpoetry.com.