Write goals in observable or measurable terms whenever possible.
MEASURABLE
Problems that arise from normal developmental needs or that requires only minimal nursing support
Low priority problems
Includes adequacy of community-based resources
Resources
It is when either the short term goal was achieved but the long term goal was not, or the desired outcome was only PARTIALLY attained
Goal partially met
It is realistic for the patient’s capabilities in the
time span you designate your goal.
ATTAINABLE AND REALISTIC
3 other factors that can also be considered when setting priorities
- THE PROBLEMS THE PATIENT FEELS ARE MOST IMPORTANT IF THIS PRIORITY DOES NOT INTERFERE
WITH MEDICAL TREATMENT - EFFECT OF POTENTIAL PROBLEMS
- COSTS, RESOURCES AVAILABLE, PERSONNEL, TIME NEEDED TO PLAN FOR AND TREAT EACH OF THE PATIENT’S IDENTIFIED PROBLEM
Completion of the implementing phase
DOCUMENTING NURSING ACTIVITIES
(Guidelines for Writing Goals)
T or F
Derive each goal from multiple nursing diagnosis
FALSE
Derive each goal from ONLY ONE nursing diagnosis.
3 types where nurses can group diagnoses
- High priority problems
- Medium priority problems
- Low priority problems
It is realistic for the nurse’s level of skill and experience.
ATTAINABLE AND REALISTIC
(Type of Nursing Interventions)
actions that the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dieticians, and physicians; those performed jointly by nurses and other members of the health care team
Interdependent/Collaborative Interventions
________ will be more likely to carry out the care
Nurse
T or F
The nurse writes the chosen/planned nursing
interventions on the care plan.
True
It describes a change in the patient’s health status or functioning
Goal
4 PRINCIPLES IN IMPLEMENTATION OF NURSING CARE
a. maintaining the individuality of man
b. consideration for the patient’s safety, comfort and privacy
c. considering economy of time, effort and materials
d. neatness of the finished product
Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION
Goal:
Body temperature will decrease from 38.50C to 37.50C within 2 hours after administering TSB.
Patient’s behavior – body temperature will decrease
Criteria of performance – from 38.50C to 37.50C
Time – within 2 hours
Condition – after administering TSB
It is included in nursing care that which you hope to achieve with your patient.
ESTABLISHING CLIENT GOALS OR DESIRED
OUTCOMES
To be able to record client responses and/or changes in the client’s status, ________ data collection is necessary
continuing
What are the 7 things nurse should identify when planning nursing interventions?
- WHAT is TO BE DONE
- WHEN the ACTIVITY is to be done
- DURATION for EACH INTERVENTION
- any FOLLOW UP activity
- date interventions were selected
- SEQUENCE in which nursing activities are to be performed
- SIGNATURE of the NURSE writing the plan of care
If care has been ________ to other health care personnel, the nurse responsible for the client’s overall care must ensure that the activities have been implemented according to the care plan.
delegated
The nurse performs nursing interventions to resolve or reduce the identified nursing problem of the patient, with the patient, and for the patient.
Implementation
What does SMART means in writing goals?
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time bounded
any treatment based on clinical judgment and knowledge that the nurse performs to enhance patient outcomes
Nursing Interventions
Determine the PATIENT’S BEHAVIOR, CRITERIA OF
PERFORMANCE, TIME, AND CONDITION
Goal:
Verbalization of decreased pain from a scale of 2 to 1 (where 3=severe, 2=moderate, 1=mild, 0=no pain) within the shift.
Patient’s behavior – verbalization of decreased pain
Criteria of performance – from a scale of 2 to 1 (where 3 = severe, 2 = moderate, 1 = mild, 0 = no pain)
Time – within the shift
Condition – not stated
