Care Plan: Having trouble making my pt goals more specific...

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Hello :)

I'm working on a care plan and one of my nursing dx is Disturbed sensory perception (visual and audio) related to altered sensory reception. I have a short term goal that states "pt will express feeling of comfort and autonomy" but I know my instructor will want to know how they would do that. What kinds of things might they say to you?

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

it would be really helpful if you would tell me what the evidence (symptoms) is of this disturbed sensory perception (visual and audio). the reason is because your nursing interventions will focus on treating those symptoms. your goals, then, are the predicted results of those interventions. it is unmistakable that either the symptoms of the disturbed sensory perception (visual and audio) and/or the etiology of it are going to be affected by your interventions. your interventions will have one of the following overall effects on the change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli (page 163, nanda international nursing diagnoses: definitions and classifications 2009-2011), the definition of disturbed sensory perception:

  • improvement of the problem
  • stabilization of the problem
  • support for the deterioration of the problem

goal statements have four components:

  1. a behavior
    • this is the desired patient response/action you expect to see/hear as a direct result of your nursing interventions.
    • you must be able to observe the behavior

[*]it is measurable

  • criteria that identifies exactly what you are measuring in terms of
    • how much
    • how long
    • how far
    • on what scale you are using

[*]sets the conditions under which the behavior should occur

  • such conditions as
    • when
    • how frequently

    [*]take into account the patient's overall state of health (this requires knowing the pathophysiology of their disease process)

    [*]take into account the patient's ability to meet the goals you are recommending

    [*]it is a good idea to get the patient's agreement to meet the intended goal so both the nurse and the patient are working toward the same goal

[*]have a realistic time frame for completing the goal

  • long-term goals usually take weeks or months
  • short-term goals can take as little time as a day
  • it all depends on knowing what your nursing interventions are designed to do and what you believe your patient is capable of doing.

let's break your goal statement into the four components: pt will express feeling of comfort and autonomy

  • behavior: the desired response that can be observed is that the patient is going to "express feeling"
  • measurable: i think you are trying to convey that comfort and autonomy are the measures of comfort, but you do not identify how. how are you going to measure feelings of comfort or autonomy? when i see the word comfort i think of the word "pain" and the diagnosis of acute pain; when i see the word autonomy i think of "independence" and the self-care diagnoses.
  • conditions: none stated
  • time frame: none given

the burning question i have is what do feelings of comfort and autonomy have to do with with vision and hearing disturbances? disturbed sensory perception (visual and audio) is not a psychosocial diagnosis. the goal you have is more of a psychosocial/behavioral one and makes no sense for a patient who has problems with vision and hearing. a person with visual and hearing problems should have goals that express improved hearing and visual perception (you did mention that the etiology of this problem is altered sensory perception), actions learned and performed that compensate for the altered vision and hearing, address orientation or other goals that relate to symptoms the patient has of the disturbed sensory perception (visual and audio). it also makes me wonder if the patient's problem has been diagnosed correctly and your nursing interventions are appropriate. i can't tell, however, because no data regarding this patient's symptoms or nursing interventions have been posted.

see these websites for suggested goals/outcomes and nursing interventions:

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