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