Patient Focussed Goals
I have found that there are a variety of influencing factors to consider while assisting an adult patient to set personal health goals in community or hospital settings. Careful consideration of all aspects of a client’s current health situation before and during discussions involving goals may enhance the patient’s capacity to co-actively identify their goals and make sound healthcare decisions about their plan of care.
Assess Coherence
Is the client alert and orientated to person, place and time? Is the client cognitively able to make decisions or identify health goals? If the client is found to be confused/mentally incompetent following a cognitive assessment, then is there a family member/caregiver that is legally responsible for the client? I have found psychiatric consults, social work, and occupational therapy assessments to be valuable resources to sort out these issues.
Other factors that may affect a client’s cognitive abilities include infections, abnormal blood sugars, abnormal bloodwork levels such as electrolytes, low oxygen levels, exhaustion, or other diagnosis that can cause an altered mental state such as a stroke or brain cancer. Some medications, such as narcotics commonly used to relieve pain, can also affect decision making.
I have found that nurses can help increase a client’s orientation and decision making ability by checking oxygen saturation levels, blood sugar levels if relevant, and bloodwork results to ensure the results are within the normal range. Investigating acute confusion or worsening chronic confusion, ensuring a patient has adequate rest, assessing for side effects to medications, and assessing what time of day is best for decision making (some individuals have more difficulty making decisions later in the day) are also helpful to increase decision making abilities.
History
A thorough history completed at the time of the client’s admission identifies the client’s physical and psychological health concerns, current medications, types of alternative medicine used, allergies, spiritual or religious beliefs, cultural practices, and includes a current head to toe health assessment completed by the MD and nurse.
During this assessment I like to inquire about their lifestyle (active or sedentary), dietary habits, sleep issues, communication problems, disabilities, and methods the patient uses to relieve stress. Knowledge of this history helps me to customize my approach to co-actively identify goals and create a plan with the patient.
Assess Desire
Does the client have a desire to learn more about their health issues, identify goals, and understand possible plans or paths to recovery? What are the patient’s priorities? Sometimes patients are overwhelmed by their situation,and are not able to focus on goals. Recent loss of a loved one, a traumatic event, extreme pain, depression, or being in a medically or psychologically unstable state can all influence desire. These issues may need to be dealt with first.
I have found that patients that have a desire to set goals generally have a greater commitment to identifying their goals, creating a customized plan, and have the required motivation to implement their plan.
Assess Physical Abilities
What activities of daily living is the client able to accomplish independently and what is the patient’s current prognosis? This knowledge guides the nurses, healthcare team, and client to set up realistic health care goals.
I personally believe that everyone is unique and that realistic healthcare goals are set with the understanding that anything is possible. I have seen many miracles and believe the human body is very resilient and with the right resources can recover from a variety of illnesses. I believe that keeping an positive open mind is important and that patient’s beliefs can influence their recovery.
Assess Baseline Knowledge
How knowledgeable is the patient about their diagnosis and current healthcare concerns? Are there knowledge gaps that need to be addressed by the nurse or other healthcare professionals. While teaching the patient health professionals should consider the patient’s educational and professional background and ask the client how they prefer to learn? There are many methods of teaching/learning that the patient can choose from to maximize their learning experience. I have found that increasing a client’s knowledge base before goal setting can enhance a client’s capacity to identify their goals and make sound healthcare choices.
Communication Abilities
A sore throat, persistent cough, laryngitis, shortness of breath, aphasia, dysphasia, dysarthria, apraxia, visual or auditory impairments, and inability to speak the local language are examples of health conditions that can make communication a challenge. Consultation with a speech language pathologist or speech and language therapist, can help identify the type of disorder that is affecting a patient’s communication abilities and will provide guidance to the rest of the health care team and caregivers that are communicating with the patient. Use of a interpreter that is fluent in in the patient’s language or that is competent in American Sign Language (ASL) can also help to ensure the patient can express their concerns, knowledge gaps, and desired goals. Lip reading, writing on paper or computer, are additional ways patients can communicate.
I have also found that ensuring the patient has their hearing aides, glasses, and any medicines to lesson persistent cough or shortness of breath also helpful. In my practice, I have found that sitting face to face, maintaining eye contact (if culturally appropriate), listening to a client without interrupting, repeating what I have heard to ensure understanding, speaking clearly and if necessarily loudly (for client’s with some hearing loss), discussing one topic at a time, using language that is easily understood (lesson use of medical jargon or technical terms), finding answers to questions in a timely manner, and use of required consults has helped me to foster a effective communication style with my patients. It is also valuable to listen to the patient’s tone, word choice, and non-verbal behaviour. Ask about their feelings around this experience. Ensuring time for questions and providing the patient with a written copy of their goals and plan of care are other ways to ensure the communication is clear. I believe that accurate communication between nurse, healthcare team, and the client is critically important to ensure the patient is fully supported to achieve their goals.
Tool for Goal Setting
| Health Concern | Goal | Current Resources | Resources Required | New Medications/Treatments | Plan | Evaluation date |
Assess Goal-Setting Environment
I have found that home environments tend to have less distractions than hospitals and are better for goal setting. Hospital environments can be challenging with many visual and auditory distractions. Other distractions may include exhaustion, pain, hunger, nausea, feeling hot or cold, recently receiving bad news, or feeling worried about something.
The nurse can assess for these possible distractions before goal setting and give medications, food, adjust the temperature, help the patient to problem solve or lesson any stressors, choose a quiet comfortable area, or promote rest time prior to goal setting. Additional measures can be implemented for patients with visual or auditory challenges. Ensure the room is well lit to optimize sight. Place a ASL interpreter beside the nurse or the facilitator of the meeting so that they are both in the client’s view. Look directly at the patient for the entire conversation, not the interpreter. Maintain eye contact and keep your mouth visible for lip reading. Graphics, pictures, and hand gestures may also be helpful, when appropriate.
I believe that taking steps to lesson distractions helps clients to remain focused on goal identification and creating a plan. Important information can be missed with frequent distractions.
Identification of Resources
Assessment of the patient’s resources before goal identification can help identify family members or caregivers involved in the patient’s care, spiritual supports, cultural practices that are health promoting and stress relieving, alternative medicine practices, financial resources/concerns, home environment, current equipment utilized, and current specialists, MD’s,and healthcare workers involved in the patient care.
Resources that are required for successful goal achievement can be identified when goal setting with the patient. Additional hospital and community resources such as social work, speech language pathologist or therapist, occupational therapy, physiotherapy, dietitian, religious or spiritual supports, or specialists can be consulted as necessary. I believe that understanding the client’s resources can help to identify gaps and understand resources that are required for optimal health.
Conclusion
Encouraging the patient to identify their health concerns and what is the most important goal to them helps to empower them during a time when many patients feel a loss of control. I feel I can help patients to achieve their goals by linking them with resources, advocating their needs to other healthcare professionals, finding the answers to their questions as soon as possible and helping them to set goals and implement a plan. Maintaining a positive attitude (share stories of inspiration) and imagining myself in their situation helps me to co-actively create individualized goals and a care plan that is customized to their needs. It is important to remember that every patient is unique.
