OB care plan

[filthy]

Hi everyone!

I'm having a hard time coming up with a goal for my care plan. Here is my nursing diagnosis Acute pain r/t dilation of the cervix and pressure on adjacent structures s/t childbirth and failure of epidural

And here is the goal I have come up with

Pt will achieve maximum level of comfort after medication administration AEB pain rating of 4/10 or below and verbalization of correct use of the PCA pump

Any suggestions?

[Daytonite, BSN, RN]

It would have been nice to see the patient's symptoms and some of your nursing interventions to see if they match with your goal. At least one your patient's symptoms needs to be that they have pain above 4/10. Two of your nursing interventions need to be to give pain medication and monitor her pain level on a 0 to 10 pain scale as well as teaching of the use of the PCA pump.

You have put 2 goals together in one statement. Break them up.

You do not have any time frames regarding when these goals are to occur.

I would not use the wording "maximum level of comfort" because it is vague. It would be good enough to say: By ___ patient will verbalize a pain rating of 4/10 ___ minutes after receiving a dose of ___.

Verbalization of the correct use of the PCA pump is not a good way to word that. If you've ever used a PCA pump you would be aware that it takes all of a few seconds to teach someone how to use it. It is more appropriate to have a goal that has the patient demonstrate how to use it. Believe me, they will "get it" and press the button to get the pain medication right away. So, your goal should be written as: By ___ the patient will successfully demonstrate the correct use of the PCA pump or By ___ the patient will self-use the PCA pump correctly to obtain pain relief.

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.
  

[filthy]

Wow...you are amazing! Do you teach?? Thank you for all your help!

[Daytonite, BSN, RN]

Any teaching I do I do here on allnurses. I am a disabled and retired RN who worked for 28 years in med/surg.