I have looked at a lot of the previous posting about working on care plans for class. Like many others, I am overwhelmed and confused!! I feel like my instructor isn't given us good explanation to go about creating one. But I have taken some considerations from these previous posting. However, I am stuck with some long term goals/interventions/rationale/evaluation. So here is what I have for Nursing Diagnosis: Impaired Comfort r/t lack of ease, relief, and transcedence in physical, psycho-spiritual, environmental, and sociocultural dimensions. The followings are short term goals and long terms goals that I have so far:
Short term goals: Patient will state her pain level at 1 to 2 within 20 minutes of analgesic.
Long term goals: Patient will maintain stated level of comfort during hospitalization which will be measured by:
1. Assessing client’s level of comfort on an hourly basis. Sources of assessment data to determine level of comfort can be subjective, objective, primary, or secondary.
2. Patient will be repositioned every hour. Ambulation will begin daily with a goal of 10 feet. Once goal is obtained, an additional 5 feet will be added per goal met. A review comparing the study by Chair et al found its results to be consistent with other studies that have found that backrest elevation, side lying, and early ambulation all improved comfort.
3. Patient will be educated to the use of relaxation techniques that may reduce her pain and fatigue, and enhance her personal well-being daily. In a systematic review of randomized controlled studies, it was found that relaxation training was effective for decreasing pain intensity, depression, and fatigue in clients with chronic musculoskeletal pain.
So, I was told by instructor that we need 5 long term goals and this is where I am stuck with. My Nursing Diagnosis Handbook only has a handful for this Nursing Diagnosis (Impaired Comfort). I may be wrong but correct me... I cannot use other Nursing Interventions from other Nursing Diagnosis other than the one I have, right? If anyone can also give me example on interventions/ evaluation, I would greatly appreciate it as well. My apology in advance that this is so long, and perhaps does not even make sense, but I am over my head with trying to figure out more long term goals, interventions, and evaluation!
