How to Set Patient Goals with Timing/Pt Awareness Challenges

I was posed a question at the OR meeting….how do they set patient goals when time may be so limited with the patients, there’s no one but staff and an unconscious or sedated patient available in the majority of their areas?

Cheryl Barger RN MSN Clinical Specialist, Special Projects, William Beaumont Hospital-Royal Oak | phone 248-551-0154

2 Responses to “How to Set Patient Goals with Timing/Pt Awareness Challenges”

  1. Ruth Says:

    Why is this patient having the surgery? What is the purpose? when we are clear on his purpose we can not only be sure we are doing the RIGHT surgery and site, but also can individualize care.
    so, for example

    Mr. Jones:
    “Mr. Jones, tell me about what’s most important to you about this surgery?”
    A: “well I really had so much knee pain it was like crushed glass when I walked. I can’t stand it”
    “OK Mr. Jones, we will be giving you a new LEFT knee, as you have marked it, and we hear that a couple of weeks after a total knee replacement, people are walking pretty well with their walkers or canes and finding they don’t have to use many pain medications like before.” (his goal, get rid of LEFT knee pain)
    this can all be done while you are determining you have the right patient and right surgery. (Time yourself: 10 seconds? 15?) this also helps focus the patient’s healing on his preferred outcome.

    Mr. Peterson
    Nurse: “Mr. Peterson, tell me what’s the main purpose of this surgery for you today?”
    A: “well don’t YOU know?”
    Nurse: “Yes, we know that we are exploring what’s going on in your abdomen, but we want to be sure we individualize your care and doing the right surgery for the right patient is always our number one concern.”
    A: “well you are right but they are looking for cancer. I am really scared b/c I don’t want to have to have chemo and radiation and stuff. I hear it’s terrible. I have a lot of abdominal pain now.”
    Nurse: “If there is a cancer, there is so much we can do now to treat any kind of cancer the doctor may find today…but the relief of your pain could be a result of this surgery also. We will keep track of your pain level as a priority during this whole hospital stay.”

    Ms. Smith
    Nurse: “Ms. Smith, we see you are scheduled for a coronary bypass graft today. What’s most important to you right now as you think about your surgery?”
    Ms. SMith: “well I can’t breathe well enough to take care of my grandkids. THat’s why I agreed to get this surgery done. Also I hope you don’t kill me off on the surgery table. I hear hospitals are terrible these days and give you MRSA.”
    Nurse: “We have excellent surgical results at this hospital and you are in the expert hands of our crackerjack cardiac team today. We will focus on getting your heart fixed up so you can keep up with those grandkids! How old are they?”
    Ms. Smith: “I am happy to hear you are good! they are 4, 6, and 2 years old and they love their grandma.”
    Nurse: “well you focus on those grandkids and we will do what we do best!”

  2. Jeanne Frentsos Says:

    In incorporating RROHC in our day to day care at the bedside we must also consider how we establish a healing relationship with those patients we care for with dementia and confusion. How do we get their input as to their problems? How do we establish their number one goal? Obviously this is a challenge to those of us who care for these patients. However, it is not something we should ever give up on. These patients are sent to us because of their need for care although we may need to spend extra time and effort to hear what their expression of those needs actually are at a given moment. Here are a few tips that might help:
    1. Nonverbal communications may be the only option in some patients that struggle to speak with you. Facial grimacing can signal pain, as can guarding of the abdomen or an extremity. Refusal to eat may signify nausea or oral discomfort. Kicking off covers may help to identify a temperature spike or fever. Even our nonverbal patients try to communicate their problems to us. We must be very sensitive and open to their methods of communication.
    2. Sometimes communicating with patients with dementia is much improved by our use of short sentences and phrases. Asking “Would you like something to eat this morning?” would be better stated with “Food?” or “Hungry?” that requires a yes or no answer or nod of the head.
    3. Enter the communication with a confused patient in a calm manner. Use of physical cues gently applied to announce our arrival at the bedside can often aid in communication. Prior to speaking with the patient announce your presence by softly touching their hand or looking them in the eye when you are speaking to them.
    4. Talk to family members and care takers. They are the primary resource for you in learning how to best communicate with the patient experiencing dementia. These individuals can cue you into what works, doesn’t work, aggravates and/or calms the patient’s confusion. Often patients with dementia have common terms or words they will utilize when expressing specific needs. Caregivers can also share with you specific situations that often lead to fear for the patient (such as bathing) and tips to help avoid this reaction while hospitalized.
    5. Try to always give the patient two options and have them select, if they are capable. Show them a chair or a wash basin/wash cloth. State “Bath or chair?” Speak slowly and clearly emphasizing the two options. This permits the patient to be more involved in their own care.
    6. Determine if the patient is able to answer “yes” or “no” questions accurately. If so attempt to focus your questioning of the patient to things they can response to with one of these answers.

    Needless to say, caring for the patient with dementia can be quite difficult at times. Despite the difficult factor, they have a right to still express themselves and have their voice heard. Because of their vulnerability and challenges in communication we must be especially vigilant and cautious on protecting their rights and treatment in a respectful manner.

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