I need help with a care plan for Chronic Confusion!!

[AshleyNWesley]

I am in my first semester of nursing school. I am still trying to figure out how to word things. I know what I want to say in my head but when it comes to documenting and phrasing it appropriately I am having trouble. I know I will get the hang of it eventually buuuut that leads to my question..

So my Dx for my pt is Chronic Confusion. The short term goal I have is: the patient will remain safe and free from harm by the end of shift. Ok the problem with the short term goal is its not SMART (specific, measurable, attainable, realistic, timely). I am missing specific and measureable. Could someone give me an example for a short term goal for chronic confusion that would meet all of the SMART requirements.

Little bit of background on my pt. She has Hx of dementia, HTN, angina pectoris, generalized weakness, RLS, constipation, depression. She is completely independent and walks with a walker. Anything else you would need to know in order to answer my question just ask.

ANY AND ALL ADVICE IS HELPFUL!! :)

Here is the care plan for anyone who would care to critique it!

Chronic Confusion R/T dementia AEB taking dementia medications, impaired short term/ long term memory, progressive long standing cognitive impairment, and scoring 24 on SLUMS.

Interventions with rationales:

1. Administer medications as ordered- medications may be used to manage symptoms of psychosis, depression, or aggression.

2.Remove potential hazards such as sharp objects and harmful liquids- Pts with dementia lose ability to make good judgments

3.Keep environment quiet and non-stimulating- sensory overload can result in agitation

4. Maintain reality and orient to environment with use of clocks, calendars, and seasonal decorations- to help orient pt back to reality and reduce confusion

[JustBeachyNurse, LPN]

There aren't goals listed in my nanda book only diagnosis, definition, defining characteristics, related factors, (or definition and risk factors) with references listed at the end of the section.

Are you referring to a care planning book that has goals & interventions? It should always be patient specific.

[quirkystudent]

There aren't goals listed in my nanda book only diagnosis definition, defining characteristics, related factors, (or definition and risk factors) with references listed at the end of the section. Are you referring to a care planning book that has goals & interventions? It should always be patient specific.[/quote']

Yeah I have the nurses pocket guide and there's goals listed. I know they have to be patient specific but didn't know if they had to include what the book says like "keeping the patient safe while maintaining maximum independence" because the book specifically states safe or if it could be completely different like "doing 30 minute checks to prevent elopement" crappy example but I think you understand.

[JustBeachyNurse, LPN]

Care plan books are guides not standards like NANDA, NIC & NOC. so if you looked in 5 different care plan guides you'd likely find different syntax, goals & interventions. They'd be similar but more of a guide than a standard.

[nurseprnRN, BSN, RN]

Grntea I have a question for you. When making your goals do you need to use the goals listed in the NANDA book? I know they have some specific ones in there. Maintaining safety (may not be exact wording) is listed for that diagnosis and if I remember right it was the only one listed. Or are you able to make it more patient specific? That's something I'm confused on.

There are no goals in the NANDA-I 2012-2014.

I know that many students call care planning handbooks "nanda books" or "NANDA books" but this is not accurate. (I often say, "There is no such thing as 'a nanda.' ")

The NIC/NOC book I cited earlier gives a bazillion evidence-based standards re interventions and outcomes measurements (JustBeachyNurse has neatly given you the difference between a guideline and a standard). Perusing them will help you in two ways: 1) it will give you some language to use for and ideas about your individual patient's needs, and 2) it will open your eyes to many more goals/outcomes and interventions to meet them that you wouldn't be expected to know or intuit/guess by yourself, because you are learning. But you'll know them now. :)