[ARRR10]

I just got my first acute care plan and I had almost everything right except for my diagnosis. Here is my diagnosis and my outcome followed by the recommended outcome by the instructor:

NS Dx: Acute pain r/t irritation of the inflamed pancreas AEB abdominal pain @ 3(0-10) and patient stating "I'm just feeling a little pain around my stomach."

My Outcome:

Short term- Client will describe how unrelieved pain will be managed (such as possible gallbladder surgery) by xx/xx/xx.

Long term- Client will perform activities of recovery (such as ambulation and use of incentive spirometer) w/ reported acceptable level of pain throughout hospital stay..

Instructor recommendations:

Short term- Client will report a decreased pain level 1/0-10 by xx/xx/xx


Long term-Client will request pain medication at ordered times and report relief by xx/xx/xx

I spoke to my instructor and she told me that the outcomes did not relate back to my Ns Dx and that mine was theoritical and not concrete. She also added that it needs to be focused on the patient. I'm having difficulty finding the reason why my diagnosis is different from my instructor. The reason I chose the outcomes is because it was listed in the recommended outcomes in Ackley and Ladwig Nursing Diagnosis Handbook under acute pain. Am I missing something here? Any help would be appreciated.

[Daytonite]

Outcomes are always directly related to what your interventions for the patient's symptoms were. Your patient's symptoms (defining characteristics) that support your nursing diagnosis of Acute Pain were:

• abdominal pain @ 3(0-10)
• patient statement of "I'm just feeling a little pain around my stomach."

Your nursing interventions should have addressed these two things specifically. Outcomes are to be the predicted results of our independent nursing actions and need to be measurable, patient centered, and specific. Your instructor's suggestions for goals (outcomes) are just that

• (this related to your first client symptoms of "abdominal pain @3(0-10) Client will report a decreased pain level 1/0-10 by xx/xx/xx. The decreased pain level of 1/0-10 is the measurable, patient centered, specifically predicted result that you would expect to occur as a result of the nursing interventions you listed to be performed.
• (this relates to your second client symptom of the patient statement "I'm just feeling a little pain around my stomach") Client will request pain medication at ordered times and report relief by xx/xx/xx. Since this involves a subjective statement by the patient, your instructor allowed for that in the goal by stating that the client will request pain medication at ordered times and report relief. I would have to see some of your interventions because I suspect that some of this outcome may be grounded in the interventions that you wrote around this particular symptom (patient instructed to request pain medication and the ordered times?).

The NOC outcomes that are given in Ackley/Ladwig (or any other nursing diagnosis reference, for that matter) are purely suggestive and are derived from the NOC Outcomes of (1) Comfort Level (2) Pain Control, and (3) Pain Level. Those are actually subject NOC topics from a work called Nursing Outcomes Classification (NOC), third edition, by Sue Moorhead, Marion Johnson, and Meridean Maas. These topics include many, many other listings for outcomes than what Ackley/Ladwig have listed in their book. Keep in mind that a book like Ackley/Ladwig is a reference. You have to apply the nursing process to the development of your care plan. You need to go back into your Ackley/Ladwig book and read Section I (pages 2-15) which is about how to make a nursing diagnosis and write a care plan. An important sentence is the second one in that first paragraph under the title "Outcomes" on page 7 which says, "Nursing-sensitive outcome is an individual, family or community state, behavior or perception that is measured along a continuum in response to nursing interventions." It is so subtle that you could miss it. That means exactly what I said in the first sentence of my reply to this thread. Hopefully, I said it in a way that was easier to understand. They also mention, very subtly, that the difference between an outcome and a goal is the fact that an outcome is more of a concept that doesn't have a specified date of achievement, whereas a goal does. Your instructor added specific dates to her goals/outcomes. Since you didn't with your goal/outcomes, she arguably can say your goals/outcomes were more theoretical (conceptual) and that also comes right out of Ackley/Ladwig. Putting a date on her goals made them more time sensitive and measurable. She just hit you in the face with some Ackley/Ladwig reality and you missed it coming. Some research I have done on this also indicates that an outcome is based upon independent nursing actions, whereas goals are more often based upon collaborative actions (interventions involving doctors orders, the efforts of other people on the healthcare team as well as the independent actions of nurses). That holds some reason since goals would be achieved much quicker with a team of healthcare people working together to bring about a desired effect.

What you are missing is the meaning behind what the steps of the nursing care process is. You still are not understanding the critical thinking behind the formation of a nursing diagnosis, goals and nursing interventions. It all starts and is based upon your assessment of the patient and proceeds from there. I write and answer questions about this all time. You can read about it in these first two threads and a couple of other specific posts I've listed:

• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)
• http://allnurses.com/forums/2248200-post6.html
• http://allnurses.com/forums/f205/myocardial-infarction-nursing-care-plan-223788.html#post2200663
• http://allnurses.com/forums/f50/need-help-dreaded-care-plan-please-223744.html

There is a lot of information here for you to process. Read it, sleep on it, go over it again. Then, go back to your instructor to regurgitate it all to clarify that you now understand it. This is crucial because your next care plan will depend on understanding this process. Everything from your assessment to your interventions to your goals are all related to each other like a large wheel that goes round and round with spokes that connect all the parts. Because each patient care plan is unique, so must each care plan be unique and cannot necessarily be totally copied from a nursing diagnosis book. Your Ackley/Ladwig book is a reference for you to use, much like any dictionary or encyclopedia. But, you have to supply the thinking that goes into the care plan. That involves an understanding of the underlying medical disease process and pathophysiology, knowledge of normal medical and nursing treatments and what each step of the nursing process entails.

[ARRR10]

Hmm... Ok, so like the interventions should lead up to my client's goals. It should be specific,measurable, achievable, relevant, and have a time-framed. I think I just need a bit more practice, but I think I am getting the idea of what the client's goals are supposed to be about. Thanks again Daytonite

[ZooMommyRN]

Originally Posted by ARRR10

. It should be specific,measurable, achievable, relevant, and have a time-framed.

#1 is always pt oriented then all the preceding you pointed out, just keep this in mind each time and you'll do fine! Also look into getting your own care plan book, they really explain the outcomes and rationales so much better then any of my text books ever did

[Daytonite]

Originally Posted by ARRR10

Hmm... Ok, so like the interventions should lead up to my client's goals. It should be specific,measurable, achievable, relevant, and have a time-framed. I think I just need a bit more practice, but I think I am getting the idea of what the client's goals are supposed to be about. Thanks again Daytonite

If one of your interventions is:

Intervention: Query patient 4 hours after last dose of pain medication to see if another dose is needed.

Think about why you are writing an intervention like that and what you are hoping to accomplish. The goal is a matter of writing it in the appropriate accepted nursing language.

Goal: Patient will report a pain level of 1/0-10 by xx/xx/xx.

[fitnessangel25]

The most important things about goals is that they have to be specefic and measurable. Unfortunately, the further I have got along in my program, the less I have used my nursing dx book. Our teachers want us to think more critically on our own instead of use the book word for word. Of course that is hard to do right away (i don't know what semester you are in). Think simply. For example: Risk for Falls
Goal: The client will not fall by discharge. Also, if the goal is educational, the best way for a client to meet that goal would be to demonstrate or verbalize education given. For ex: The client will demonstate the drawing up and injecting of insulin by discharge.