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Help with STG/LTG for Care Plan!

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by Bealstar Bealstar (New) New

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Hello everyone!

I am doing my care plan for my patient and I am having a very hard time writing goals. My teacher sent it back to me and I have to fix every goal but I am at a loss here. My patient is on the LTACH and her admitting Dx is VDRF. She has a trach, G tube, on telemetry, and bilateral wrist restraints. I'm having trouble with the goals since they must be patient centered, however, my patient is not able to do anything for herself. My nandas are:

1. ineffective airway clearance r/t artificial airway aeb retained secretions and needs to be suctioned q2h.

2. Decreased cardiac output r/t altered heart rhythm aeb atrial fibrillation on telemetry and hypertension.

3. Impaired skin integrity r/t nonhealing wound aeb hysterectomy wound draining foul smelling discharge for 4 years.

4. Impaired verbal communication r/t artificial airway aeb patient is unable to speak.

5. Imbalamced nutrition: less than body requirements r/t inability to ingest food aeb patient is NPO, receieves Nepro @45mL/h through G tube, low sodium (143), low potassium (3.7), low calcium (8.8), low protein (8.1), and low albumin (2.6).

If anyone can help me write patient centered goals for any of these nandas please help me out!

Thank you in advance!

Jessica

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1,035 Posts; 6,846 Profile Views

1) There is no such thing a "a NANDA." And no handbook or other text has all of the NANDA-I approved nursing diagnoses with defining and related factors. (If they did, it would be a copyright violation).

Step back a bit. Look at this lady. Wave a magic wand and ::bippity-boppity-boo!:: she's your grandmother.

What do you want for her?

See, goals aren't something you pull out of the air. They come to you because you look at the patient and say to yourself, "What do I want to have happen here? How will I know that what I plan to do is working/having desired results/preventing what i wanted to prevent?"

Nursing diagnosis is part of you looking at somebody (like your grandmother in the bed there), planning what should happen to her while in your care, and knowing how to know if what you planned to do and/or delegate to others is working. This doesn't mean "Following orders." We have to implement parts of the prescribed medical plan of care, but that is not what this question (and a huge part of your education AND a big part of what nurses do) is about. This is about nurses planning the nursing part of the patient's care, which is actually usually more than half of what they do.

So... noodle about that a minute and then come back and let us know what you think. This is an exercise in learning how to think like a nurse. Your sentences should start out with something like, "My Nana will ...." or, "My Nana will not ..." and end with something like "during (time period)" or "by date" or "at discharge" ....

If you have the NANDA-I 2015-2017, you can see under the defining characteristics for each nursing diagnosis and related factors (the causes) enough for you to set some goals for your grandmother there in the bed. Please get it and put it to use-- you'll be ahead of your classmates if you do.

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