Recent Question/Assignment

21/08/2019

Establishing a Goal with Desired Outcomes
HOW TO DEVELOP A GOAL OF CARE
A desired goal / outcomes serve the following purposes:
• Provide direction for planning nursing interventions
• Serve as a criteria for evaluating a person’s progress
• Provide a point of motivation
Goals can be for either short term or long term and need to be directly related to the nursing diagnosis. They also should specify both an action and timeframe,
Goals and desired outcomes should be specific, measurable and written in terms of the person’s responses/behaviour (not the nurses). They also need to be realistic for the person.
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21/08/2019
Developing Interventions
HOW TO DETERMINE A COURE OF ACTION TO MEET THE SET GOAL
Interventions refer to the ‘take action’ phase of the CRC and may include a combination of cognitive (thinking), interpersonal (communicating verbally and non-verbally) and technical (hands on) skills
Interventions need to be:
• linked to nursing diagnosis and goal/desired outcomes
• based on evidence (and align with policy and/or legislation)
• be appropriate for the person (culture, preferences, values and beliefs)
• orientated to promote wellbeing and rehabilitation
• provide teaching, support or comfort to the person
Example:
Nursing Diagnosis: Ineffective airway clearance from chest infection related to viscous secretions and shallow chest expansion
Goal / Desired Outcome Implementation / Interventions Rationale
Goal:
Improved respiratory gas exchange within 24-48 hours
Desired Outcome:
• Absence of pallor and cyanosis
• Respirations 12-22 breaths/min; pulse 100 beats/min
• Use of correct breathing and coughing technique Monitor vital signs and respiratory status every 4 hours; including breath
rate, depth, effort, skin and mucous membrane colour
Referral and review by physiotherapist to assist in respiratory care.
Instruct to perform breathing and coughing technique every 3 hours and maintain Fowler’s or semiFowler’s positioning. To identify progress towards or deviation from goal. Inadequate oxygenation causes increased pulse rate (reference expected)
Interdisciplinary review to create appropriate and individualised breathing and coughing exercise plan. (reference expected)
To enable coughing of secretions and full expansion of lungs (reference expected)
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