stuck on goals for unresponsive pt

Nursing Students General Students

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Specializes in Dialysis.

I am extremely stuck on expected outcomes.

For my 1st nursing diagnosis I used, Ineffective airway clearance R/T immobility secondary to CVA. For the outcomes I used 1. Pt will not aspirate for 4 hours. ( that was the length of time I cared for him) 2. Pt Oxygen sat. will be at 95 before noon. How do they sound. Pt was unresponsive so it's difficult for me to know I am doing this right.

For a 2nd diagnosis I am using Risk of Infection R/T a site for organism invasion secondary to total parenteral nutrition. For an outcome I am at a loss, I have absolutely no idea what to say. I am only there 5 hours. Please help someone!!!!!!!!!!!!!!!!!!!

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Specializes in Urgent Care.

How about pt will have a temp less than 100° for duration of shift?

Insertin site will remian free from redness or edema?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you can almost always make your goals the opposite, or the positive expression, of what the patient's symptoms, or defining characteristics, are for each particular nursing diagnosis. unfortunately, you didn't list any of these for your first nursing diagnosis. while your goals sound good, i don't know how well they relate to the actual symptoms the patient is having. was he having a problem with aspirating his secretions? or, just a problem with secretions in his airway that needed removal? your goals have to relate to the patients symptoms you used to pick that diagnosis.

when you are using an anticipatory nursing diagnosis, your goals are always to remain free of the symptoms that would be the cause of that problem. so, a goal for risk of infection would be for the patient not to demonstrate and signs or symptoms of infection (list them out).

i have a problem with the wording on your nursing diagnoses. ineffective airway clearance is defined as the "inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway." nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 6. the cause of this airway obstruction is not the patient's immobility. there is no doubt that is it contributing to the problem, but it is not the cause of it. the cause, or "related factor" (your r/t part of the nursing diagnostic statement) needs to be one of these problems:

  • retained secretions
  • excessive mucus production
  • presence of a tracheostomy or endotracheal tube
  • bronchial secretions
  • neuromuscular dysfunction [possibly from the stroke?]
  • copd
  • infection
  • asthma

in addition, you don't have to qualify the cause by saying it is secondary to the cva. cva is a medical diagnosis and you shouldn't be using medical diagnoses in your nursing diagnostic statements!

risk for infection is defined as "at increased risk for being invaded by pathogenic organisms." nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 108. what site for organism invasion are you making reference to? you should specify. you don't need to use tpn to qualify the site of this possible infection. it doesn't make sense to me anyway. tpn is not going to cause an infection unless the solution is contaminated. the risk factors, or "related to" potential causes for infection would be:

  • invasive procedures [placement of the central line, endotracheal tube or tracheostomy, foley catheter or anything else they had to make a hole to stick something into the patient]
  • traumatized tissues or broken skin
  • immunosuppressants [is (s)he getting steroids?]
  • malnutrition
  • increased exposure to pathogens [suctioning, dressing changes to the central line]
  • leukopenia
  • presence of a chronic disease

strongly suggest that you look through the posts on these threads to get a better understanding of how to write a nursing diagnostic statement and choose nursing diagnoses:

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In addition, you don't have to qualify the cause by saying it is secondary to the CVA. CVA is a medical diagnosis and you shouldn't be using medical diagnoses in your nursing diagnostic statements!

In my school we are being taught to qualify our diagnosis using secondary to (medical diagnosis) routinely. We can only use the medical diagnosis as a secondary to, but are expected to do so whenever we can.

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