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Nursing Care Plan Goals and Interventions

The goal of a nursing care plan is to prevent a potential problem from occurring, to maintain a present status or level of functional ability, or to resolve a currently existing problem. Goals are usually stated in terms of an action the resident will perform. The elements to focus on in writing Nursing Care Plan goals are that it is:

Appropriate for the resident’s needs, strengths, abilities, and cultural background
Realistic, reasonably, and  attainable
Measurable; able to be objectively observed and evaluated
Resident centered  and stated in terms of the residents’ actions
Time framed  to give a target date, or time estimate for attainment of the goal
Individualized to the resident’s unique deficits, traits, and preferences
Specific to each problem and has a goal specific to it, although each problem may have more than one goal

Examples:
1. Resident will wash face and hands during morning care every day.
2. Resident will verbalize understanding of the need to comply with diabetic diet.
3. Resident will lose one pound per week over the next thirty days.

Nursing care plan interventions describe specific actions taken by long term care staff member’s to achieve the stated goal, and are based on standards of clinical practice.

The Code of Federal Regulations, F281, states that the services provided or arranged by the facility must meet professional standards of quality and be provided by qualified persons in accordance with each resident’s written nursing care plan.

Like goals, interventions need to be specific, measurable, appropriate, and realistic. Interventions are worded in terms of what the staff will do to assist the resident to meet the stated goals for the problem, such as: Offer the resident four ounces of fluid, eight times per day.

“Professional standards of quality” means services that are provided according to accepted standards of clinical practice. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body, or other regulatory agency.

Recommended practices to achieve desired resident outcomes may also be found in clinical literature. Possible reference sources for standards of practice include such sources as: Current manuals or textbooks on nursing, social work, physical therapy, etc.

Standards are published by professional organizations such as the American Dietetic Association, American Medical Association, American Medical Director’s Association, American Nurses Association, National Association of Activity Professionals, Clinical practice guidelines published by the Agency of Health Care Policy and Research, and in many current professional journal articles.


Guest Article by Debra Collins RN, RAC-CT, and Pedagogy author of multiple Inservices and Compliance online education courses for certified nursing assistants, CNA’s, and home health care aides.  As CEO and President of LTCS Books, Inc., Debra maintains a knowledge base and writes weekly articles on long term care and home health care federal regulatory changes.

As CEO and President of LTCS Books, Inc., Debra maintains a knowledge base and writes weekly articles on long term care and home health care federal regulatory changes.

She has written and published twelve books for long term care and home health care documentation. Her publications include care plans, policies and procedures, and quality assurance audits for Directors of Nursing, Administrators, Nursing, Restorative Nursing, MDS Coordinators, Social Services, Activities, and Infection Control. The books are used by over one third of long term care facilities in the United States.

Debra has over 25 years of experience in long term care and home health care. She worked as an MDS Consultant for many years, and is certified as a Resident Assessment Coordinator by AANAC, the American Association of Nurse Assessment Coordinators.

She is a member of the National Nurses in Business Association, National Association for Female Executives, American Business Women's Association, Bloomington Indiana Chamber of Commerce, and Ladies Who Launch.

Posted: 7/24/2013 1:10:43 PM
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