10.02.2008

Case Example with Goals

A review of "recent keyword activity" leading to the blog indicates that there's a lot of people out there looking for example goals and treatments for different diagnoses. I'll try to do some posts in this direction, please don't plagiarize them for your school assignments.

Here's a walkthrough case to see the clinical reasoning behind the goals that are written, and a few example goals.


CASE: Mr. X is a 65 y.o. s/p THR on the acute orthopedic floor. He lives alone, has a tub/shower, and was previously independent with all I/ADLs. He would like to return to full independence.

SETTING BACKGROUND
: Heads up- in an acute hospital, your basic joint replacement patients w/o significant comorbidities or post-op complications will leave the floor in 3-5 days. Case management will look to therapy to determine where this person will go (home, SNF, acute rehab). The lack of time for intervention means that your treatments need to cut to the point, so you can give an accurate expectation of how the client will perform in the continuing days, and whether they must have continuing care.

IMPORTANCE
: Goals at this level of care have to reflect the quick pt. turnover. What are the most important things for Mr. X to learn and demonstrate before he discharges to maximize his safety and independence?

My ranking: hip precautions; basic mobility; LE dressing; advanced mobility (tub transfer, standing tolerance); home safety. Your clinical reasoning may place importance in a different order, here is my reasoning. He must know hip precautions before moving, to prevent dislocation and repeat surgery. He must be able to stand and take at least 1-2 steps so that at the very least he can get from w/c to BSC, and to facilitate dressing. We have no evidence from our brief case that this man would have any difficulty w/ UE dressing, but he cannot be independent unless ADL retraining is performed for LE dressing. He needs to be able to put on pants and shoes, or he is not going to have anything resembling independence upon discharge. At the point that he can stand up long enough to put pants on, he is probably ready to progress to advanced mobility, and I consider tub transfers to be especially important. It's better to review this in a controlled environment before the pt. goes home and decides to do it anyway. And home safety is always a good thing to work on with your patient, to try to prevent falls and maximize independence. If you, like me, do not get to leave the hospital to investigate the home, you will have to get creative with this.

GOALS
In 3-5 visits, pt. will...
1. verbalize and demo 3/3 hip precautions (we are assuming he doesn't have the extra 'no active abduction' precaution)
2. transfer to BSC w/ CGA and assistive device
3. don socks w/ sock aid independently
4. don pants w/ AE prn and CGA (I almost always use the "AE prn" phrasing since different devices work better for different people, and I have actually seen a person don pants independently w/o any device while observing hip precautions)
5. perform safe tub transfer to extended TTB w/ CGAx1
6. verbalize/demo 3-5 home safety techniques



The best way to get better at writing goals and treatment plans is to practice and get feedback from a trusted advisor- professor, supervisor, etc. The best exercise I know for this is detailed in this simple document. I have not completed an example there as this was an assignment from one of my teachers, and surely others are using it as well.

1 comment:

bumbzie said...

very helpful thanks