care plan direction

[serenity59]

Hi, I am 3rd semester RN student, I am doing my first care plan and I am perplexed, I am doing OB, have to have DX. which I can do, but then we got 2 have 2 goals to that as evidenced by, that trips me up, do I put pt. will show adq. hydration as evidenced by good turgor , ect? :banghead:I understand all the rest of it , could someone help?

[vashtee, RN]

Have a look here. It is very useful.

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_030.php

[Daytonite, BSN, RN]

i'm glad you found allnurses.

we have help for writing care plans on the student forums.

care planning follows a logical sequence and i can tell by your question that you are very much out of the logical sequencing. so, let me see if i can get you back on track.

goals are the results you expect to see happen when your interventions for the patients nursing problem(s) are followed.

you say you put "patient will show adequate hydration as evidenced by good turgor, ect". so, i'm guessing that the patient's problem and nursing diagnosis is probably deficient fluid volume, yes? your interventions for this probably are things like making sure the patient is given fresh water and lots of oral juices and other fluids, that you instruct the patient about the importance of replacing fluids, that ivs are given as prescribed, that she is monitored for skin turgor, thirst, dry oral membranes, sunken eyeballs, weakness, complaints of headache and onset of confusion. . .that kind of thing. stop a minute and think what the aim of doing these things is. that is your goal. how do you know if these interventions will work? assess. you needed evidence (that aeb stuff - symptoms/abnormal data) to prove that a problem existed to begin with. once the problem is solved, you will need normal assessment data (the opposite of the symptoms/abnormal data) to prove that your interventions worked! so, your goal statements will include normal assessment data. make sense? now, you just have to put it into words--that's the hard part, isn't it?

i guess one analogy of all this is to think of the patient getting stuck up a tree (the problem), you figured out when and how to get them down (the goal statement) and now you have to hold a press conference and tell the world exactly how you're going to do it (the interventions).

this post on one of the stickies in the student forums, explains what 4 elements need to be incorporated into the construction of a goal statement: https://allnurses.com/forums/2509305-post158.html. some instructors like them written in a form similar to the nursing diagnostic statement. that is ok too because if you think about it the goal is the problem reversed, or made positive.

hope that was helpful for you. if not, please don't hesitate to ask for more assistance.