Nursing care plans are written tools that outline nursing diagnoses, interventions, and goals. Care plans are especially useful for student nurses as they learn to utilize the nursing process. By creating a nursing care plan based on a patient’s assessment, the nurse learns how to prioritize, plan goals and interventions, and evaluate outcomes related to specific disease processes. Care plans are essential for communication between nurses and other care team members in order to provide high-quality, continuous, evidence-based care.
Developing effective nursing care plans is a crucial skill for nurses. A key component of care plans are the goals set for patients Goals provide direction for the interventions and actions needed to help patients improve their health By setting SMART goals, nurses can create focused, achievable targets that optimize patient outcomes. In this article, we’ll explore what SMART goals are and provide tips for incorporating them into nursing care plans.
What are SMART Goals?
SMART is an acronym that outlines the key characteristics of well-constructed goals, SMART stands for
- Specific
- Measurable
- Attainable
- Realistic
- Timely
Let’s break these elements down further:
Specific
Goals should clearly identify what you want to accomplish. Using vague or broad goals leaves too much room for interpretation. Effective nursing care plan goals zero in on the exact changes needed to improve the patient’s health.
For example, a vague goal would be “Patient will have less pain”. In contrast, a specific goal would be “Patient will report pain as 2 or less on pain scale of 0-10”.
Measurable
There must be a way to quantify or assess progress toward the goal. Measurable goals allow nurses to track improvements and determine if interventions are working.
Going back to our example, reporting pain on a standard 0-10 scale provides a measurable way to monitor progress. Other measurable indicators could include vital sign changes, lab values, or ability to ambulate a certain distance.
Attainable
Goals should be achievable based on the patient’s condition, prognosis, and capabilities. Attainable goals give patients a target within reach. This empowers motivation and effort.
For a frail elderly patient, a goal to ambulate independently within 2 days may not be attainable. A better goal could be to sit at bedside for 10 minutes with minimal assistance.
Realistic
While goals should inspire effort, they must also be grounded in reality. Realistic goals consider limitations that could impede progress. Factors like comorbidities, cognitive status, support systems, and access to resources should inform goal setting.
A patient eager to get back to marathon running after hip surgery may need a more realistic goal at first, like walking 1 mile per day pain-free.
Timely
Goals should have a clearly defined timeline. Timely goals create urgency and prompt more efficient interventions. Timeframes could range from hourly to monthly depending on the clinical situation.
Rather than a vague “pain will be improved” goal, a timely goal could be “Patient will report pain as 4 or less on 0-10 scale within 24 hours”.
Tips for Writing SMART Goals
With the SMART criteria in mind, here are some tips for writing effective nursing care plan goals:
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Avoid broad, vague goals – Goals like “normalize vitals” or “wean oxygen” are too open-ended. Get specific about parameters and timeframes.
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Focus on patient priorities – Let the patient’s main concerns and desired capabilities drive appropriate goal setting.
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Consider baseline status – Set goals that target reasonable improvements from the patient’s current baseline. Big leaps may not be feasible.
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Collaborate with patient – Incorporate patient preferences and make sure they agree goals are achievable. This boosts engagement.
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Include metrics and timeframes – Quantify the progress you expect to see within set time periods. Don’t just state a desired outcome.
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Evaluate resources – Consider access to tools/staffing needed to reach goals. Avoid goals that resources can’t reasonably support.
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Review regularly – Re-evaluate goals frequently. Adjust timeframes or measures if progress stalls. New clinical developments may warrant changes too.
SMART Goals Nursing Care Plan Examples
To illustrate how SMART goals translate into nursing care plans, here are two examples:
Respiratory Goal
Patient is a 65 year old male with COPD exacerbation. Current oxygen saturation is 88% on 2L nasal cannula.
Broad goal: Improve oxygenation
SMART goal: Patient will maintain oxygen saturation >90% on <2L nasal cannula for 24 hours by [date].
Pain Management Goal
Patient is a 50 year old female postoperative after total knee replacement. Current pain score is 8/10 on 0-10 scale.
Broad goal: Decrease pain
SMART goal: Patient will report pain as 4 or less on 0-10 scale within 12 hours of surgery by [date/time] with oral pain medication.
The Benefits of SMART Goals for Care Plans
Using SMART goals in nursing care plans offers many advantages:
- Creates patient-centered plans with targets matched to readiness and preferences
- Provides clarity for nurses on expected progress and outcomes
- Allows quantitative monitoring to assess efficacy of interventions
- Promotes optimal recovery by setting achievable steps
- Empowers patients and boosts engagement in their care
- Facilitates efficient coordination across interdisciplinary teams
- Enables easier progress tracking and documentation
- Identifies specific needs for resources and adjustments to care
In today’s healthcare environment, nurses must deliver evidence-based care that maximizes quality and safety for patients. SMART goals are a simple yet powerful strategy to focus nursing care plans toward these priorities. The specific, measurable, attainable, realistic, and timely framework guides care teams in setting and working toward defined health targets. While it requires diligence and effort, applying SMART goal principles enables nurses to create and execute nursing care plans that truly optimize patient outcomes.
Examples of Collaborative SMART Goals
Here are two examples of how SMART goals can be used in care planning:
Goal: “The client will rate their pain three or less on a scale of 0-10 by discharge.”
- Specific: The goal includes an exact number on the pain scale acceptable to the patient.
- Measurable: The goal can be tracked over time and measured on the pain scale.
- Attainable: This depends on the specific patient context, but for the example, we will assume this is an achievable goal for the patient.
- Realistic: Similarly, this goal must be realistic, which will depend on the patient’s pain tolerance.
- Time-bound: In the inpatient setting, ‘by discharge’ is an appropriate time frame.
Goal: The patient will demonstrate independently using a glucometer to check their blood sugar and how to self-administer necessary insulin after three diabetes education sessions.
- Specific: The goal includes specific behaviors and outcomes of the education sessions.
- Measurable: The nurse can assess if the goal is complete by asking the patient to demonstrate their skills.
- Attainable: The patient has the motor and cognitive ability to learn these skills.
- Realistic: Enough time has been given for practice and education so that the patient feels comfortable and confident.
- Time-bound: This goal is set to be achieved after three education sessions. At the end of the third session, the nurse can assess if the goal has been met or if more support or time is needed to meet this goal.
Standardized vs. Individualized Care Planning
Care plans can be either standardized or individualized for the patient. Many care settings will use standardized care plans for specific patient conditions to deliver consistent care. One example of a standardized care plan is the post-operative care pathway used in post-surgical units. These post-operative care plans outline expected goals for each post-operative day. However, standardized care plans should be tailored when possible to the needs of the individual patient.
In contrast, individualized care plans are created for individual patient needs. Individualized care plans should include input from the patient whenever possible to create personalized goals and support patient adherence. When creating an individualized care plan, consider the patient’s health status, history, and motivational factors and inquire about what matters most to them.
Care plans enter the nursing process at the planning stage but are influenced by all other steps. The steps of the nursing process can be remembered with the acronym ADPIE.3
- Assessment
- Diagnosis
- Planning
- Implementation/Interventions
- Evaluation
Here is a breakdown of the nursing process:
1. Assessment: Assessing the client’s needs, gathering data In the assessment phase of the nursing process, the nurse collects and analyzes objective and subjective data. Then, the nurse uses their nursing knowledge and critical thinking skills to decide if further assessments are necessary to identify a nursing diagnosis.
2. Diagnosis: What’s going on? Crafting a nursing diagnosis Based on data collected during the assessment phase, the nurse crafts a nursing diagnosis that can be used to direct care planning.4 The nurse should assign a nursing diagnosis using the standardized terminology laid out by NANDA-I. A nursing diagnosis is a clinical judgment that describes actual or potential health problems or opportunities for health improvement of a patient, family, or community.
3. Planning: Time to create goals In step three of the nursing process, the nurse, ideally in collaboration with the patient, creates goals of care based on the nursing diagnosis. A care plan, including interventions and expected outcomes, is created to achieve these goals.
4. Implementation: Time to act In the implementation phase of the nursing process, the nurse takes actions and performs the interventions described in the care plan to achieve the goals of care. The nurse uses their knowledge, experience, and critical thinking to decide which interventions are a priority. Often, interventions are based on orders from the physician.
5. Evaluate: What are the outcomes? In the evaluation phase of the nursing process, the nurse reassesses the patient to determine if the intervention has the desired outcome. Next, the nurse should evaluate if the goals of care have been met or require more time. If the intervention does not have the desired effect, the nurse should consider if the care plan needs revision or if the goals of care need to be updated.
Here is an example of how the steps of the nursing process fit together.
The nurse assesses the client who was in a motor vehicle accident. The client reports a pain level of 9/10 in their right shoulder. Through an x-ray, the client is determined to have a dislocated shoulder, and the nursing diagnosis of acute pain is applied. The nurse begins planning treatment and goals to reduce pain and instill comfort. The nurse administers IV pain medication as ordered and supports the right arm with pillows. The nurse evaluates the effectiveness of interventions by asking the client to rate their pain on a scale of 0-10. Depending on the outcome, the nurse may determine that the intervention was successful or requires revision.
How Utilizing SMART Goals Helps Improve Patient Care
What are SMART goals in nursing care?
Customizes patient care: SMART goals can help create a customized treatment plan for patients, which may help improve the patient’s well-being and treatment progress. Enhances patient morale: SMART goals in a nursing care plan may also improve a patient’s morale and motivation.
What are SMART goals for patients?
Setting SMART goals for your patients can help you create a more effective nursing care plan, which is a tool nurses use to evaluate, measure and monitor a patient’s progress. Learning more about SMART goals and how to include them in your treatment plans can help you provide more effective care for your patients.
What are the benefits of SMART goals?
Using SMART goals in this process may have the following benefits: Improves collaboration: Setting clear goals and steps can help a health care team collaborate effectively. Nurses can divide goals into small actionable steps, and each team member can work to treat the patient.
How do you write goals on a nursing care plan?
After you set your criteria and deadlines, you can write each goal on the nursing care plan. Typically, each goal is about one sentence long and includes the deadline and criteria. For example, you might write a goal for a patient to reach a blood pressure and heart rate within the acceptable limit before discharge from the hospital.
