Patient Care Plan - Pharmacology

Once a nursing diagnosis is reached, a care plan is developed that describes how the healthcare team will address the patient’s problems. It contains

  • Nursing diagnosis
  • Expected outcomesGoal statement
  • Interventions based on a scientific and medical rationale needed to achieve the goal
  • How to measure each outcome

GOAL STATEMENT

At the heart of the care plan is a goal statement that specifies an expected outcome of the health care team’s intervention with the patient. Think of a goal statement as what you want to happen to the patient. For example, a typical goal is that a patient will report a reduction in pain from 8 to 4 on a scale of 0 to 10 in three hours.

A goal statement is a nursing order that must be patient centered and specify a desired behavior to occur at a specified time. The behavior must be observable and measurable and the goal statement must specify criteria for measuring the behavior.

Ideally, both the nurse and the patient develop and accept the goal. If the patient’s decision-making ability is impaired, then the patient’s family or another support person becomes the patient’s advocate in the planning process. It is critical that the patient adopts the goal statement; otherwise, the goal might not be achieved. For example, if the patient doesn’t believe in taking pain medication, then a goal of reducing pain by taking analgesics will not be met. The nurse will then have to explore alternatives to pain medication such as a massage or imagery. The care plan should be shared with the patient’s family, the healthcare team and others who are caring for the patient so that everyone is working toward the same goals.

DEADLINES AND MEASUREMENT

It is important that the care plan establish realistic deadlines for reaching the goal, otherwise the patient and those caring for the patient will become frustrated when the goal is not met. For example, it isn’t realistic to say that the patient will no longer cough after taking dextromethorphan (Robitussin DM) simply because the medication isn’t an instant cure for coughing. A more realistic goal is for the frequency of the patient’s coughing to decrease after each dose. The deadline might be that the patient will take dextromethorphan for 48 hours and report a decrease in frequency of coughing and experience uninterrupted rest. This goal is both observable and measurable since the nurse can observe if the patient is coughing and measure the frequency of the cough to determine if the goal is reached.

INTERVENTIONS

The care plan must also specify the intervention for each goal statement. An intervention is a clear statement that specifies the action that must be taken to achieve the goal statement. An intervention must complement the goal statement, use available resources, follow protocols established by the healthcare facility, and always keep the patient’s safety in mind.

There are three types of intervention.

Nurse-initiated intervention

A nurse-initiated intervention is a nursing order performed independently by the nurse based on a scientific rationale that benefits the patient in a predicted way, such as removing a blanket to lower the patient’s temperature.

Physician or advanced practice intervention

This type of intervention is a dependent function issued by a physician or an advanced practitioner that is carried out by a nurse, such as administering prescribed medication to the patient.

Collaborative intervention

A collaborative intervention is an activity performed among multiple healthcare professionals, such as physical therapy for the patient.

EVALUATION

Each outcome on the care plan must be evaluated to determine if the goal is achieved. Once all goals on the care plan are reached, the care plan no longer exists. The patient no longer exhibits symptoms of the nursing diagnosis. However, if one or more goals are not realized, reassessment or data collection should occur. This would include reassessing the patient and other factors, such as schedules, availability of resources, and developing new goals, interventions, and evaluations.


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