Based on the nursing assessment and diagnosis, the next step in the nursing process is to create a nursing care plan. Care plans are a map for personalized care tailored to a patient's unique needs. The patient’s overall health condition and other health issues or comorbidities play a role in the creation of a care plan. Care plans promote communication, documentation, and continuity of care.
Constructing a care plan is centered around obtaining patient-specific goals to ensure a positive outcome. The nurse sets SMART goals (specific, measurable, attainable, realistic and time-oriented) for this plan, which are both short- and long-term goals. Examples of a short-term goal would include walking outside for 20 minutes three times per day; maintaining adequate nutrition for two weeks by eating 5 small, frequent meals. Long-term goals would include managing high blood pressure by keeping it at 120/80 through adequate medication and lifestyle for 6 months.
The “S” in SMART stands for “specific.” When creating a goal, it is important that it be specific to the individual patient and tailored to their needs, including their comorbidities, overall health status, and day-to-day life. The goal needs to be very clear and show who, what, when, where and why.
The “M” in SMART stands for “measurable,” meaning that you can actually measure and evaluate the progress of that patient’s goal in a concrete way.
The “A” in SMART stands for “attainable.” This means there are actions that can be taken to reach the goal in a way that is patient-specific.
The “R” in SMART stands for “realistic.” This means that achieving the goal is realistic to the patient’s lifestyle and ability, and the goal is realistic to achieve.
The “T” in SMART stands for “time-oriented.” This means that there is a specific end time frame or date which the goal is going to be evaluated.
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