Need help with care plan goal page!

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OK, this is crazy, I really need some help or guidance, I guess I'm just not getting it. I turned in a care plan and as usual my goal page is not right. we have to include long & short term goals for our patients. My long term goal was: Pt will start to mobilize secretions by 2030 on 03/24/07. My short term goal was: Pt will list 3 interventions being used to mobilize secretions by 2030 on 03/23/07. These goals "are not pt centered, they are medically centered" how do I make it Pt centered? I feel like such a dope! Any suggestions? Please tell me this will get easier.

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Specializes in Peds HH, LTC.

what is the patient's diagnosis that you are trying to work up?

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Ineffective airway clearance r/t infection m/b ineffective cough

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Specializes in Peds HH, LTC.

some patient oriented outcomes are:

Patient (client) will:

-Maintain airway patency

-Expectorate / clear secretions readily

-demonstrate effective coughing and clear breath sounds; is free of cyanosis and dyspnea

-demonstrate behaviors to improve or maintain clear airway

-identify and avoid specific factors that inhibit effective airway clearance

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So if I use: "Pt will maintain airway patency through discharge on 03/24/07" for a long term goal could I use " Pt will cough and deep breath to mobilize secretions by 2030 on 03/23/07" for a short term goal, since coughing and deep breathing works toward maintaining airway patency.

Thanks for your help,

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Specializes in Peds HH, LTC.

It sounds good. When I had to work up care plans with patient outcomes, I always used "during hospital stay" or something along those lines. I didn't have to pinpoint long and short term goals.

But it makes sense that the ultimate goal is to maintain the airway, and the short term goal is actually a mini goal (step) which will achieve the ultimate goal. Does that make sense?

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Yes, thanks that really helped.

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

What your instructor is getting at is that your goals must be based upon independent nursing interventions, not nursing interventions that are following medical orders.

I'm looking at the suggested NOC outcomes (goals) linkages for Ineffective Airway Clearance in my copy of Nursing Outcomes Classification (NOC), Third edition, by Sue Moorhead, Marion Johnson and Meridean Maas. This gives expanded details on the outcomes normally listed in the care plan books. Here are some of the things listed:

Aspiration Prevention (definition: personal actions to prevent the passage of fluid and solid particles into the lung):

Have the patient demonstrate:

  1. identification of risk factors
  2. avoidance of risk factors
  3. how to position self upright for eating/drinking
  4. selection of foods according to swallowing ability
  5. how to position self on side for eating and drinking as needed
  6. choosing liquids and food of proper consistency
  7. hoe to use liquid thickeners as needed

Respiratory Status: Airway Patency (definition: open, clear tracheobronchial passages for air exchange):

The patient will have any degree (severe, substantial moderate, mild) or no degree of:

  1. ease of breathing
  2. respiratory rate
  3. respiratory rhythm
  4. moving sputum out of the airway
  5. moving blockages out of the airway
  6. anxiety
  7. fear
  8. choking
  9. adventitious breath sounds

Respiratory Status: Ventilation (definition: movement of air in and out of the lungs):

The patient will have any degree (severe, substantial moderate, mild) or no degree of:

  1. depth of inspiration
  2. symmetrical chest expansion
  3. ease of breathing
  4. moving sputum out of the airway
  5. vocalization
  6. percussed sounds
  7. auscultated breath sounds
  8. auscultated vocalizations
  9. Bronchophony
  10. Egophony
  11. Whispered pectoriloquy
  12. Accessory muscle use
  13. adventitious breath sounds
  14. Chest retractions
  15. Pursed lips breathing
  16. Dyspnea at rest
  17. Dyspnea with exertion
  18. Orthopnea
  19. Shortness of breath

Anxiety Level (definition: severity of manifested apprehension, tension, or uneasiness arising from an unidentifiable source):

The patient will exhibit any degree (severe, substantial moderate, mild) or no degree of:

  1. restlessness
  2. pacing
  3. hand wringing
  4. distress
  5. uneasiness
  6. muscle tension
  7. facial tension
  8. irritability
  9. indecisiveness
  10. outbursts of anger
  11. problem behavior
  12. difficulty concentrating
  13. panic attacks
  14. verbalized apprehension
  15. verbalized anxiety
  16. exaggerated concern about life events
  17. increased blood pressure
  18. increased pulse rate
  19. increased respiratory rate
  20. sweating
  21. fatigue

There are more titles I could have looked under:

  • Allergic Response: Systemic
  • Asthma Self-management
  • Cognition
  • Endurance
  • Immune Hypersensitivity Response
  • Infection Severity
  • Neurological Status
  • Pain Level
  • Post Procedure Recovery Status
  • Respiratory Status: Gas Exchange
  • Risk Control: Tobacco Use
  • Symptom Control Treatment Behavior: Illness or Injury
  • Vital Signs

Let me know if you want to see any of the outcomes listed under any of those titles and I will post them for you.

Now, if you look at the outcomes I've listed above, one thing about them should stick out like a sore thumb. Do you see it? They look almost exactly like some nursing interventions! And, not only nursing interventions, but independent nursing interventions--things you can do without a doctor's order. Many of them, I noticed had to do with the assessment of the patient's respiratory status. You must see, however, that your nursing interventions link very closely to outcomes (goals). The result of your interventions should be your goals.

Some time ago I undertook a search of literature to get the difference in the definitions between a goal and an outcome. Some instructors, I believe, do not make this distinction, and it may be that your instructors are among this group. However, I will tell you what I found in my searching. The newer term of use is the word "outcome". It pertains specifically to those things that result from actions taken by nurses independent of medical orders. "Goals", on the other hand, pertain to the result of actions that include those done under medical orders. A goal of "pain will be pain free after receiving pain medication" would be a goal, not an outcome, under that definition. Go by, and do, what your instructors are telling you to do.

Take some time to read over what I've listed for you. I really don't know anything about your patient. However, you need to cogitate on the concept that your instructor is trying to get you to understand and the information I've just given you. It all fits together. It might also help for you to re-read the first chapter(s) of any care plan book that you have to see how goals and nursing interventions fit together and are related to each other in a care plan.

One the goals you listed was

  • Pt will start to mobilize secretions by 2030 on 03/24/07

I would refine it more like this

  • Patient will do a return demonstration by 2030 on 03/24/07 of how to correctly position himself, take a deep breath and cough productively to successfully remove sputum from his airway.

or something similar.

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WOW,

Thanks for all the info, I never expected to get so much help on this. I wish I had found this website a long time ago.

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can anyone think of a short term goal for a pt with decreased cardiac output?

Pt is hemiplegic, a fib, diabetic, hypertension....the list goes on....

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Specializes in med/surg, telemetry, IV therapy, mgmt.
can anyone think of a short term goal for a pt with decreased cardiac output?

pt is hemiplegic, a fib, diabetic, hypertension....the list goes on....

a short term goal for your patient is going to based upon their signs and symptoms (or abnormal data items) that you found during your initial patient assessment. you should have developed your nursing interventions for this care plan from them. then your goals are formulated from the predicted results of those nursing actions (nursing interventions) that you developed for this care plan. since you have provided none of that information, i can't help you write a goal. anything i would suggest would be out of a textbook, only a suggestion and might be way off base based on the problems your patient is having. care plans are customized to the patient. sorry.

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