Need Pt Goal Assistance

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Hi, I need a goal that will work for this 'patient'.

We are working on a care plan and I came up with a nursing diagnosis of impaired oral mucous membranes. Our patient is an 88 yo male, recent left side CVA, right sided hemiplegia with dry tongue and cracked lips, NPO and on an NG tube (this is not a 'real' person, it is a simulated patient that our instructor had us assess).

I need a patient goal that would work with my diagnosis and the patient's medical diagnosis - anyone have any ideas for a good SMART goal for this patient?

I have my nursing interventions - provide oral care q2 hours per shift and consult Dr for additional free water in NG tube to help with hydration. I'm just not sure what to have the patient goal be - I know it needs to address the nursing diagnosis, I am just not sure where to go from here.

Thanks in advance - :bow:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

impaired oral mucous membranes means that the patient has disruptions (openings) in the soft tissues of the lips and/or oral cavity (this is the definition of this diagnosis. his cracked lips are the evidence of this. what have you determined these cracks are due to? the reason i ask is because it does affect your 3-part nursing diagnostic statement and quite possible your goal(s).

interventions are aimed to treat the symptoms that are causing the problem. i see you are thinking that hydration is the cause of the cracked tongue. is it? you said the patient has an ng tube. is he getting tube feedings and water through this tube? if so, then how could he be dehydrated if his food and fluid is being controlled by the medical and nursing staff? did you look up all the signs and symptoms of stroke? did mouth breathing show up? is it possible he has some paresis of the muscles of his face and jaw which might cause his mouth to be open and why he might be breathing through an open mouth all the time, thus, having a dry mouth? is his tongue paralyzed or weak so he can't lubricate his lips properly? does he have an ng tube because of swallowing problems? did a discussion of the idea that this patient might be receiving oxygen come up and that this might also be contributing to his dry mouth?

when you are problem solving a thorough assessment of the medical problem must be done. since this patient has had a stroke he is going to have many problems. stroke leaves devastating consequences. if you have a copy of taber's cyclopedic medical dictionary you will find a reference in the appendix at the back with suggested diagnoses for a cerebrovascular accident and many other conditions. here are websites that might be helpful for you as well: [color=#3366ff]impaired oral mucous membrane and http://www.stroke.org/site/pagenavigator/home.

goals are always the predicted results you expect to see when your nursing interventions are performed as ordered. so, if the evidence of the impaired oral mucous membranes are cracked lips and they are because of ???, you order "provide oral care q2 hours per shift and consult dr for additional free water in ng tube to help with hydration" then the result you expect of all that would be. . .

there are 4 types of nursing interventions (actions):

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
  • care/perform/provide/assist (performing actual patient care)
  • teach/educate/instruct/supervise (educating patient or caregiver)
  • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

goals accomplish one of 3 things:

  • improve the patient's problem and/or its cause/remedy or cure it
  • stabilize the patient's problem and/or its cause
  • support the deterioration of the patient's problem and/or its cause

remember to follow the steps of the nursing process as you work on this care plan:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

  • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
  • your instructors might have given it to you.
  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    • care/perform/provide/assist (performing actual patient care)
    • teach/educate/instruct/supervise (educating patient or caregiver)
    • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

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Thank you Daytonite - you are a goddess! :bow:

I forgot that they mentioned partial aphasia. Since it was a simulated patient, we got some written information, but the rest is up to us to look up. Oxygen was not mentioned and the patient did not have a nasal cannula, only the ng tube. I'm assuming (and I know that is dangerous) that the dry cracked lips are partially from the aphasia and stroke.

I also considered hydration because though he is NPO, the 'patient' had his hand on the over the bed table and was 'reaching' for a cup of water that had been placed there. We removed the cup during our assessment because of his NPO status.

I do have Tabers and will do some more research.

Thank you again, I appreciate your knowledge and input.

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Oh, one other thing - though he was on liquid nutrition he had lost 3 lbs in 3 days - so I also assumed (again, dangerous) that he may not be digesting the liquid nutrition as well as he might.

I apologize for not providing better information in the initial post. I have seen other posts and know that the more information the better chance of getting an accurate response/diagnosis.

Thanks again!

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Specializes in LPN Student, next step RN.

Hi daytonite,

Maybe you can help me. I am a nursing student and this is my first NSG care plan.

Scenario: 70 y/o male with massive CVA, past medical hx DM, HTN(uncontrolled).

MY OBSERVATION: ng tube, 2 stomies, indwelling catheter, tracheostomy, edema of the foot.

I have to create a plan daling with the NG tube.....

I dont have the slightest clue where to start........

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Specializes in med/surg, telemetry, IV therapy, mgmt.
hi daytonite,

maybe you can help me. i am a nursing student and this is my first nsg care plan.

scenario:

my observation: ng tube, 2 stomies, indwelling catheter, tracheostomy, edema of the foot.

i have to create a plan daling with the ng tube.....

i dont have the slightest clue where to start........

read the above and start by assessing the patient. care planning is based upon the abnormal assessment data that is the evidence of the patient's nursing problems. your observations that you listed include the treatments that have been ordered for this patient. the only abnormal data you have is "edema of the foot". what you need are the responses of the patient to all these things that are happening to him. for a 70 y/o male who has had a massive cva and has dm and uncontrolled htn, a lot more assessment is missing. where's the vital signs? lung sounds? heart sounds? pulses? abdominal assessment? skin assessment? where are these 2 ostomies? how does this patient get their food? move? bathe? toilet? the best thing is to make a list of all the abnormal data. if you need to see how this is done, you can see examples of how this is done on https://allnurses.com/forums/f50/help-care-plans-286986.html- assistance - help with care plans.

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Specializes in LPN Student, next step RN.

My professor never gave any vitals sign. As far as the stomies they are located parallel o each other (sigmoid colon) and the (beginning of the ascending colon). The right hand of the mannequin was amputed. Skin tugor is normal. The right pupil isnt dialate. Pt has an orogastric tube.Edema of the legs. Urine output was 400ml, however i have no documentation as to how long the bag was placed/changed.

70 y/o male with massive cva, past medical hx inclues DM and HTN (uncontrolled).

This is all the information I've gathered by lookin at the mannequin.

My portion is to write a nursing care plan based on the NG tube. (Salem). I am lost....Dont know how to start....

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Specializes in med/surg, telemetry, IV therapy, mgmt.
my professor never gave any vitals sign. as far as the stomies they are located parallel o each other (sigmoid colon) and the (beginning of the ascending colon). the right hand of the mannequin was amputed. skin tugor is normal. the right pupil isnt dialate. pt has an orogastric tube.edema of the legs. urine output was 400ml, however i have no documentation as to how long the bag was placed/changed.

70 y/o male with massive cva, past medical hx inclues dm and htn (uncontrolled).

this is all the information i've gathered by lookin at the mannequin.

my portion is to write a nursing care plan based on the ng tube. (salem). i am lost....dont know how to start....

ok, so this is not a real patient situation. still. . .you were given certain facts that you must take into consideration. you still need to begin by doing an assessment as if this were a real patient.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology. - you were specifically told that the patient had a massive cva, a history of diabetes and uncontrolled hypertension. this information will be crucial to the care you will plan around the care of this n/g tube. you need to do several things before going any further. (1) look up and learn about strokes and diabetes (http://www.merck.com/mmpe/sec16/ch211/ch211a.html) and (http://www.merck.com/mmpe/sec12/ch158/ch158b.html), (2) look up and learn why a person with a stroke might have an n/g tube, and (3) what a salem (sump) n/g tube is and why it is being used rather than just a plain old straight n/g tube (http://www.icufaqs.org/ngtubes.doc).

  • massive cva (stroke)
  • dm
  • htn (uncontrolled)
  • right hand amputation
  • medical treatments:
    • salem sump n/g tube
    • double barrel colostomy
    • indwelling foley catheter
    • tracheostomy

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - stroke patients have a lot of problems that require nursing help, so it is not a mistake that your instructor assigned this kind of a case to you. you will see similar kinds of patients again and again as a nurse. you already know some abnormal things about this patient that were found on physical examination that i would say are pertinent:

  • edema of the foot - this has a relationship with the patient's htn and heart function (https://allnurses.com/forums/f50/help-pathophys-hypertension-295077.html)
  • right pupil isn't dilated - this is an abnormal finding consistent with brain damage - it would be found during a neuro check (glasgow coma scale) and would be a clue as to what part of the brain the stroke had occurred in - it is also evidence of a nursing problem since a patient with a pupil that isn't dilated means that the patient is probably having visual problems. what does the pupil do for the eye and seeing?
  • ??? related to the reason for the ng tube

you will also need to add symptoms that you feel apply since this is a made up situation. so, from the merck manual reference and another few reference i will list for you, make a list of the symptoms that occur when patients have strokes. swallowing problems are one of them. an n/g tube would be inserted in the immediate period of the stroke's occurrence to prevent the patient from vomiting and aspirating on the vomitus since the muscles of swallowing can be paralyzed as a result of the stroke or the patient could be unconscious and in a coma as a result of brain damage.

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

  • impaired swallowing

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem - this is where you write your nursing interventions for the care of this salem sump tube.

the subject of care plans for stroke patients is so popular and common that it came up again recently. on post #6 on this thread i listed a whole bunch of care plan threads that pertained to strokes that you might want to look at:

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