How can you prioritize competing responsibilities when developing a care plan?

I agree with assessing the client situation, and using all the various tools available to acquire that information. To me a successful care plan is one initiated by the care provider whoever that maybe, but lead and driven by the patient. They must feel like they are empowered to change and have complete autonomy over their choices. We as providers are there to inform, educate, and provide realistic interventions that will help our patients make informed decisions about their care.

I agree we need to assess the patient for their holistic health and well-being. Active listening and empathy are great tools for clinicians to utilize during this stage. Based on the holistic assessment, determine (with the patient) what is the most pressing need. As clinicians we might see things the patient doesn’t and so it’s important to gently point out what we notice as red flags for safety, alternative treatment options, and when to seek emergency care. I find people are generally pretty good at knowing what is missing in their social determinants of health and love having a nurse help them to fill that void.

First you listen, really listen, ask guiding questions. What is that client/patient telling you. What is the input from the family and medical team. What does your own assessment verify. Think safety and finances what avenues can you create with your client. Ask them for their top three and provide your top three and make plans from this collaborative interaction.

In my experience, it is very important for the patient to understand that they have complete autonomy, and get them involved in sharing their goals. Once this is done, your responsibility is to work within your professional reasoning, provisions, processes and standards of your organization or workplace. Assist the patient/client in refining the goals with what is realistic then engage in the plan of action together. Going forward, discuss your observations with the client and agree on a way forward (monitoring progress).

In my experience, for any plan even a contingency plan, a prior rank of responsabilities will release you for this stress. GUT matriz could help!

The importance of using measurability in goal-setting with clients also rests in the ability to ensure accurate baselines of behavior. This can be done by applying scaling questions, such as "on a range of 1-10", or "on a scale up to 100%" or "using a light system of red, yellow or green", how would you assess [insert the current baseline of behavior the client wants to change]. It's important to use the exact same measurability question over the next few months or weeks to evaluate progress, stagnancy or regression as you support the client through growth and empowerment. Progress is identified through observable and concrete movement in the scale itself, which verifies that the SMART goal is working.

Absolutely right. SMART Goals are the key to achieve complete well being of the patient. Not only it imparts good health to the patient but also gives him/ her confidence to lead a normal.healthy life. Saves time, money, energy of both the health care as well as the patient and together boosts the confidence of both.

In practice, the identification of interventions and resources is an ongoing and dynamic process. It requires collaboration among healthcare professionals, consideration of the client's unique needs, and a commitment to providing care that is both effective and client-centered. Regular assessment, evaluation, and adjustments are essential to ensure that the interventions and resources remain aligned with the client's goals and evolving healthcare needs. Interventions should be tailored to the individual client's needs, preferences, and circumstances. A one-size-fits-all approach is often ineffective. Resources should align with the specific interventions that have been planned.

I like a team approach. Service team meetings with other providers adds valuable insight. Include the client in these meetings and you have just given them so much encouragement by showing them how important they are and how everyone is working together to help them. Including them also instills the importance of their voice and their right to choose and is an opportunity to teach them to advocate for themselves.

Your client may need to understand some of the competing factors but our responsibility to manage and seek measurable outcomes for all including the client. Be willing to shift and design new plans as things change and empower the client towards progress. Have a multi disciplinary approach so all parties have clear, open lines of communication and all have same information.

Another consideration is the patient environment at home. If there are goals being set, but limited support at home it is an additional barrier to success. Considerations for nutrition and hygiene must be included in the plans, not assumed.