3. Goals (Sometimes known as "Plan" as in "I plan for this to happen")
If the problem statement/diagnosis describes the patient's current condition, the simplest way to understand goals is as predictions about the patient's state following (hopefully) successful treatment. They are the aim of care, a statement about where the patient needs to be. They are NOT fond wishes that must, perforce, apply to all patients ("the patient will not fall" or "the patient will remain infection free") rather they are individualized and specific to that problem and that patient. Goals are measurable (or binary... yes/no) such that there can be solid agreement about whether the goal is met or not. And they are stated in a time context. Revisiting the patient described above, the staff of the "nearest" hospital will doubtless begin giving the patient intravenous fluids. The nurse's logic would describe one goal of care in these terms... Within 8 hours, the patient will be making at least 30 ml/hour of urine. (Specific to this patient? Yes. Specific to this problem? Yes. Measureable? Yes. In a time context? Yes. Notice that the nurse did not say "within 8 hours the patient will get 3 liters of saline and 2 liters of saline with potassium." That would be a perfectly good nursing action or order (disguised as a goal).... but it is not a goal. Note: Because Nursing Outcomes Classifications (NOCs) are licensed, and to avoid confusion, this website will use the term "goals" in place of "outcomes". In essence, however, they are the same thing.
Some instructors want students to write one or more specific types of goal statements. These might include "1 long term and 2 short term goals". In other classwork, you might be asked to write goals for the patient, family, and the community. But the form and format of a goal should always be the same.
Some instructors want students to write one or more specific types of goal statements. These might include "1 long term and 2 short term goals". In other classwork, you might be asked to write goals for the patient, family, and the community. But the form and format of a goal should always be the same.
4. Nursing Actions (a.k.a "Implementation")
Nursing actions are just that... what the nurse does to achieve the stated therapeutic goal. A reasonable style for writing an action is to frame it as a "nursing order". These should be stated as imperatives, or as specific directions to other members of the nursing team caring for the patient. Like a medical order, the nursing order or action should specify time and frequency and, where necessary, give detail about methods. For example rather than saying "the patient needs to be ambulated" or "get the patient out of bed" a clearly articulated nursing action would specify "Out of bed in chair for meals" or "Ambulate patient 3 times this shift to nurses' station and back. Use gait belt." Note: Because "Nursing Implementation Classifications" (NICs) are licensed, and to avoid confusion, this web site will use the terms "nursing actions" or "nursing orders" instead of "interventions".
5. Evaluation and reformulation
This step in the nursing process should be as simple as falling off a log. It is nothing more than reporting whether the previously stated goal has been met... or not. If not, the plan is reformulated, which is another way of saying "back to the drawing board." If the goal has not been met, presumably there is additional assessment data that suggests the treatment has fallen short. If it's fallen short, there is either a new problem or the existing problem should be redefined. New goals are set and alternative (hopefully more successful) actions are prescribed.
The Grand Recapitulation: There are 5 steps to the nursing process (and don't let the terminology throw you off !!!)
1. Assessment: (a very broad collection of information that is sifted/sorted and focused to reveal discrete problems.)
2. Problem statement: (also sometimes referred to as "nursing diagnosis")
3. Goal(s) statement: (also sometimes called "planning" or "outcomes")
4. Actions: (also sometimes called "implementation". Can be understood as "nursing orders")
5. Evaluation/reformulation: ("Hooray!!! we met our goals" or "Back to the drawing board").
2. Problem statement: (also sometimes referred to as "nursing diagnosis")
3. Goal(s) statement: (also sometimes called "planning" or "outcomes")
4. Actions: (also sometimes called "implementation". Can be understood as "nursing orders")
5. Evaluation/reformulation: ("Hooray!!! we met our goals" or "Back to the drawing board").