need help with short term and long term goals...pls

[reba77]

I have to do two care plans on a pt I have never seen just the chart.

each care plan must have 2 short term and 2 long term goals

pt info-

81 y/o w/m

diag- periventricular leukoencephalopathy with brain atropy and calcified right vetebral artery

muscle weakness ( dressing, balance, gait and strength tested fair/poor), episodes of syncope and collapse, dysphagia (occasionally)

hx of seizure disorder.

I was thinking of using-

Risk for fall r/t PVL aeb muscle weakness, episodes of sycope and collapse, hx of seizure disorder

STG- Pt will not fall during my 8 hour shift

STG- Pt will be learn how to use assistive devices such as wheelchair and pull bars by the end of my 8 hour shift

LTG-Pt will be able to transfer from bed to wheelchair with min. or no assistance by the end of 3 months.

LTG- ?????? (not sure)

Impaired Verbal Communication r/t PVL aeb muscle weakness, poor oral motor skills, dysphagia

STG- Pt will be able to use alternative methods of communication effectively by the end of my 8 hour shift

STG- Pt will demonstrate understanding by nodding head yes/no by the end of my 8 hour shift

LTG- Pt will be able to say simple words such as yes, no, help, in the next 2 months

LTG- ???? (not sure)

please let me know if the above is ok and any suggestions would be helpful

[reba77]

Any input would be appreciated

[xokimberly]

Hey Reba,

Perhaps another LT goal would consist of pt will regain strength from weak/poor to mild/moderate. This can include strength r/t mobility and or ADL's

for dysphagia LT goal I am thinking towards nutrition, which may be impaired or ineffective due to this, so a LT goal would be for the pt to understand tolerations of consistency for solids, ie how to use thicken products, therefore pt can tolerate foods and regain nutritional values..

I hope this helped if even a little?! :)

[reba77]

Thanks alot.... I will try those:yeah:

[One Flew Over]

For the fall one, perhaps that the patient will remain safe/free from falls for the next 3 months? I would say that only because the whole focus of the careplan is falls, and I would want to address that in both the short term and long term goals. :)

And I could be wrong here, but for the verbal communication one, it seems like you're doing two careplans in one for that one? It seems like your focus there should be everything related to how the patient can express his/herself to others and dysphagia is more related to swallowing and nutrition not speaking. Nutrition is a seperate issue, which should probably be addressed in another care plan. I personally would take dysphagia out of there and focus on the other two causes.

Just my 2 cents :)

As for a long term goal, perhaps that the patient will state that he/she is satisfied with the alternative modes of communication presented to them? Or something along those lines?